What are the treatment options for vertigo?

Treatment Options for Vertigo

The first-line treatment for vertigo depends on the underlying cause, with specific interventions like canalith repositioning procedures for BPPV and vestibular suppressant medications for acute symptomatic relief in other types of vertigo. 1, 2

Types of Vertigo and Specific Treatments

Benign Paroxysmal Positional Vertigo (BPPV)

• BPPV is characterized by distinct triggered spells of vertigo or spinning sensations that are intense for seconds to minutes 1
• Canalith repositioning maneuvers (like the Epley maneuver) are the recommended first-line treatment with high success rates (around 80%) with only 1-3 treatments 1, 3
• Medications are not recommended as primary treatment for BPPV, as they do not address the underlying cause 1, 3
• Self-repositioning techniques can be taught to patients under supervision 1

Ménière's Disease

• For acute attacks, a limited course of vestibular suppressants is recommended 1, 2
• Dietary modifications including salt restriction and diuretics are used to prevent flare-ups 1, 4
• Long-term management focuses on reducing the frequency and severity of vertigo attacks 1

Vestibular Neuritis/Labyrinthitis

• Brief use of vestibular suppressants is recommended for acute symptoms 4
• Vestibular rehabilitation exercises should follow to promote compensation 4, 2

Medication Options

First-Line Medications

• Meclizine (25-100 mg daily in divided doses) is the most commonly used antihistamine for peripheral vertigo 2, 5
• It should be used primarily as-needed rather than on a scheduled basis to avoid interfering with vestibular compensation 2
• FDA-approved specifically for "treatment of vertigo associated with diseases affecting the vestibular system in adults" 5

Other Medication Options

• Prochlorperazine may be used for short-term management of severe nausea/vomiting associated with vertigo, but is not recommended as primary treatment 2, 3
• Benzodiazepines can be used for short-term management of severe vertigo symptoms and associated anxiety 2, 4
• Scopolamine (transdermal) should only be used for short-term management during acute attacks, not as long-term treatment 6

Important Cautions and Considerations

• Vestibular suppressant medications should only be used for short-term management of severe symptoms rather than as definitive treatment 2, 3
• These medications can cause significant side effects including:
  • Drowsiness and cognitive deficits 2, 5
  • Interference with driving 2
  • Increased risk of falls, especially in elderly patients 2, 3
• Long-term use can interfere with central compensation in peripheral vestibular conditions 2, 6
• Common side effects of meclizine include drowsiness, dry mouth, headache, fatigue, and vomiting 5

Lifestyle Modifications

• Limit salt/sodium intake, especially for Ménière's disease 2, 1
• Avoid excessive caffeine, alcohol, and nicotine 2
• Maintain adequate hydration, regular exercise, and sufficient sleep 2
• Manage stress appropriately 2

Follow-Up Recommendations

• Patients should be reassessed within 1 month after initial treatment to document resolution or persistence of symptoms 2, 3
• Transition from medication to vestibular rehabilitation when appropriate to promote long-term recovery 2

Treatment Algorithm

1. Identify the specific type of vertigo (BPPV, Ménière's, vestibular neuritis, etc.)
2. For BPPV: Use canalith repositioning maneuvers as first-line treatment 1
3. For acute symptoms in other types of vertigo:
   • Start with meclizine 25-100 mg daily in divided doses 5
   • For severe nausea/vomiting, add prochlorperazine for short-term use 2, 3
   • For anxiety component, consider short-term benzodiazepine 2
4. Limit vestibular suppressant medications to short-term use (days to weeks) 2, 3
5. Implement appropriate lifestyle modifications 2
6. Follow up within 1 month to assess response and transition to vestibular rehabilitation if needed 2