What is the recommended treatment approach for inpatient vertigo?

Inpatient Vertigo Treatment

The recommended first-line treatment for inpatient vertigo due to BPPV is the Canalith Repositioning Procedure (Epley maneuver), which has success rates of 90-98% when performed correctly, while vestibular suppressant medications should NOT be routinely prescribed. 1

Diagnosis and Classification

• Accurate diagnosis is essential before initiating treatment:
  • Posterior canal BPPV: Diagnosed when vertigo with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 2
  • Lateral canal BPPV: Diagnosed using the supine roll test when Dix-Hallpike shows horizontal or no nystagmus 2
• Differential diagnosis should rule out other causes of vertigo including central causes (stroke, multiple sclerosis), vestibular migraine, and Ménière's disease 3, 4

Treatment Algorithm for Inpatient Vertigo

1. First-Line Treatment for BPPV

• Posterior Canal BPPV: Canalith Repositioning Procedure (Epley maneuver) 2, 1

  • Specific sequence: seated upright → supine with head hanging 20° below horizontal → head turned 90° to unaffected side → head/body turned another 90° → return to sitting 1
  • No postprocedural restrictions are necessary 2

• Lateral Canal BPPV: Gufoni maneuver or barbecue roll maneuver (86-100% success rate) 1

2. Vestibular Rehabilitation

• May be offered as an adjunctive therapy to repositioning maneuvers 2, 1
• Can be self-administered or clinician-guided 2
• May improve long-term outcomes and decrease recurrence rates, particularly in elderly patients 2
• Brandt-Daroff exercises are less effective than repositioning maneuvers (25% vs 80.5% resolution at 7 days) but may be used in some cases 1

3. Pharmacological Management

• Important: Vestibular suppressant medications should NOT be routinely prescribed for BPPV treatment 2, 1
• Limited use of medications may be considered in specific situations:
  • Meclizine (25-100 mg daily in divided doses) for short-term management of severe symptoms 5
  • Antiemetics for management of associated nausea/vomiting 3
  • For vestibular migraine: beta-blockers, topiramate, or candesartan may be considered 3

Management of Treatment Failures

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 2, 1
• For persistent symptoms, evaluate for:
  • Persistent BPPV requiring repeat repositioning maneuvers 2
  • Canal conversion (occurs in ~6% of cases) requiring appropriate repositioning for the newly affected canal 1
  • Underlying peripheral vestibular or central nervous system disorders 2
• Success rates reach 90-98% when additional repositioning maneuvers are performed for persistent BPPV 2
• For cases refractory to multiple repositioning procedures, consider surgical options like canal plugging (>96% success rate) 1

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers 1
• Failing to reassess patients after initial treatment 1
• Missing canal conversions or multiple canal involvement 1
• Overuse of vestibular suppressant medications, which are not recommended for long-term management 3
• Inadequate neurological examination in patients with atypical or refractory symptoms, which may indicate central pathology 2
• Failing to obtain MRI of the brain and posterior fossa in patients with persistent symptoms despite multiple repositioning attempts 2

Special Considerations

• Patients with physical limitations (cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, etc.) may require modified approaches to repositioning maneuvers 2
• Central causes of vertigo require different management approaches and should be ruled out, especially in cases that don't respond to standard BPPV treatment 2, 6