What is the treatment for intractable vertigo (dizziness that cannot be controlled)?

From the Guidelines

Intractable vertigo can be effectively treated with bedside repositioning exercises, which have a high success rate of around 80% with only 1-3 treatments, as supported by the most recent and highest quality study 1.

Treatment Approach

The treatment approach for intractable vertigo should prioritize the use of bedside repositioning exercises, such as the Epley maneuver, to guide the crystals back to their original location in the inner ear.

• These exercises can be performed by a healthcare professional or taught to the patient for self-repositioning.
• The goal of these exercises is to reduce the frequency and severity of vertigo episodes.
• In some cases, vestibular rehabilitation therapy may be recommended to help the brain compensate for vestibular dysfunction.

Medication Use

Medications such as diazepam, meclizine, or promethazine may be used for short-term management of severe symptoms, but they are not recommended as a primary treatment for BPPV due to the potential for significant harm, including drowsiness, cognitive deficits, and increased risk of falls, as noted in 1.

• Betahistine may be considered for patients with BPPV, particularly those with hypertension and brief attacks, as it has been shown to be effective in reducing symptoms when used concurrently with canal repositioning maneuvers 1.

Lifestyle Modifications

Lifestyle modifications, including avoiding caffeine, alcohol, and tobacco, maintaining regular sleep patterns, and staying well-hydrated, are essential supportive measures that can improve treatment outcomes by reducing triggers and promoting vestibular compensation.

• Patients should also be counseled on the risk of falls associated with BPPV and take precautions to minimize this risk, such as assessing home safety and avoiding activities that may exacerbate symptoms, as emphasized in 1.

Underlying Cause

It is essential to identify the underlying cause of vertigo, as conditions like vestibular migraine, Meniere's disease, or vestibular neuritis require specific approaches.

• A thorough diagnostic evaluation, including a physical examination and vestibular testing, should be performed to determine the underlying cause of vertigo, as discussed in 1 and 1.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). The treatment for intractable vertigo is not explicitly stated in the label, but meclizine is indicated for the treatment of vertigo associated with diseases affecting the vestibular system.

• Key points:
  • Meclizine is used to treat vertigo.
  • The label does not specify intractable vertigo. 2

From the Research

Treatment Options for Intractable Vertigo

The treatment for intractable vertigo, or dizziness that cannot be controlled, depends on the underlying cause of the condition. Some possible treatment options include:

• Medications such as anticholinergics, antihistamines, benzodiazepines, calcium channel antagonists, and dopamine receptor antagonists to modify the intensity of symptoms or affect the underlying disease process 3
• Vestibular rehabilitation physical therapy to promote compensation for vestibular damage 3, 4, 5
• Surgical treatment, such as vestibular neurectomy, for patients with intractable vertigo due to Meniere's disease or other conditions 6, 7
• Standardized non-invasive vestibular rehabilitation training after surgical treatment involving the vestibular system to eliminate symptoms and improve postoperative quality of life 4

Specific Treatment Approaches

For patients with Meniere's disease, treatment may include:

• Vestibular suppressants such as anticholinergics and benzodiazepines to control acute symptoms 3
• Salt restriction and diuretics to prevent flare-ups 3
• Vestibular physical therapy to improve balance function and reduce symptoms 5 For patients with intractable vertigo due to other causes, treatment may involve:
• Prophylactic agents such as L-channel calcium channel antagonists, tricyclic antidepressants, and beta-blockers for migraine-associated vertigo 3
• An eclectic approach incorporating trials of vestibular suppressants and physical therapy for central vertigo due to stroke or other structural lesions 3
• Benzodiazepines for psychogenic vertigo associated with disorders such as panic disorder, anxiety disorder, and agoraphobia 3