What are the treatment options for vertigo?

Treatment Options for Vertigo

The Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice for benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo, with success rates of 90-98% when performed correctly. 1

Diagnosis and Classification of Vertigo

• Vertigo should be classified based on triggers and timing to determine appropriate treatment 2
• The most common causes of vertigo include BPPV, acute vestibular neuronitis/labyrinthitis, Ménière's disease, migraine, and anxiety disorders 3
• BPPV is diagnosed when vertigo with characteristic nystagmus is provoked by the Dix-Hallpike maneuver (for posterior canal) or the supine roll test (for lateral canal) 1

Treatment Based on Specific Vertigo Type

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith Repositioning Procedure (Epley maneuver) for posterior canal BPPV 1, 4
• For lateral canal BPPV: Gufoni maneuver or barbecue roll maneuver (86-100% success rate) 1
• Vestibular rehabilitation exercises may be offered as an alternative or adjunctive treatment 1
• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 4, 1
• For persistent BPPV, reevaluation should include examination for involvement of other semicircular canals 4

2. Acute Vestibular Neuronitis/Labyrinthitis

• Initial treatment includes stabilizing measures and short-term vestibular suppressant medication 3
• Vestibular rehabilitation exercises should follow acute management 3
• Patients should lie on their healthy side with head and trunk raised 20 degrees during acute symptoms 5

3. Ménière's Disease

• Treatment goals include reducing severity and frequency of vertigo attacks, relieving associated symptoms, and improving quality of life 4
• Low-salt diet and diuretics are often effective 3
• For persistent and disabling attacks, more invasive treatments may be considered based on hearing status 4
• Non-ablative procedures are preferred for patients with usable hearing 4
• Ablative treatments may be considered for patients without useful hearing 4

Pharmacological Treatment

• Meclizine is FDA-approved for treatment of vertigo associated with diseases affecting the vestibular system in adults 6
• Recommended dosage: 25 mg to 100 mg daily, in divided doses 6
• Vestibular suppressant medications should not be routinely prescribed for BPPV treatment and should only be considered for short-term management of severe nausea or vomiting 1
• Common side effects include drowsiness, dry mouth, headache, fatigue, and vomiting 6
• Caution should be used when prescribing to patients with asthma, glaucoma, or prostate enlargement due to potential anticholinergic effects 6

Management of Treatment Failures

• Evaluate patients with initial treatment failures for persistent vertigo or underlying peripheral vestibular or CNS disorders 4
• Canal conversion occurs in approximately 6% of cases and requires appropriate repositioning for the newly affected canal 1, 7
• For cases refractory to multiple repositioning maneuvers, surgical options like canal plugging may be considered 1

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers for BPPV 1, 7
• Failing to reassess patients after initial treatment 1
• Missing canal conversions or multiple canal involvement 1, 7
• Overlooking central nervous system disorders that can masquerade as BPPV 4