Treatment Options for Vertigo
The Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice for benign paroxysmal positional vertigo (BPPV), with success rates of 90-98% when performed correctly. 1
Diagnosis and Classification
- Vertigo must first be properly diagnosed and classified to determine appropriate treatment 2
- 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) 3, 4
- The most common causes of vertigo in primary care are BPPV, vestibular neuronitis, and Ménière's disease 2, 5
Treatment Based on Specific Vertigo Type
Benign Paroxysmal Positional Vertigo (BPPV)
- Canalith Repositioning Procedure (Epley maneuver) is first-line treatment for posterior canal BPPV 1, 4
- For lateral canal BPPV, the Gufoni maneuver or barbecue roll maneuver has 86-100% success rate 1, 4
- Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 3, 4
- For persistent BPPV, reevaluation should include examination for involvement of other semicircular canals 3
- Vestibular suppressant medications should NOT be routinely prescribed for BPPV treatment 4
Vestibular Neuronitis/Labyrinthitis
- Initial treatment includes stabilizing measures and vestibular suppressant medication, followed by vestibular rehabilitation exercises 5
- Vestibular rehabilitation therapy (VRT) should be implemented as a series of progressive exercises focusing on habituation, adaptation, and compensation 1
Ménière's Disease
- Treatment goals include reducing severity and frequency of vertigo attacks, relieving associated symptoms, and improving quality of life 1
- Diuretics and/or betahistine may be offered for maintenance therapy 3
- Intratympanic steroids may be offered to patients with active Ménière's disease not responsive to noninvasive treatment 3
- Low-salt diet combined with diuretics is often effective 5
- Positive pressure therapy should NOT be prescribed for patients with Ménière's disease 3
Pharmacological Treatment
- Meclizine hydrochloride is FDA-approved for the 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
- Caution: May cause drowsiness; use care when driving or operating machinery 6
- For Ménière's disease, diuretics and/or betahistine may be used for maintenance therapy 3
- For vertiginous migraine headaches, dietary changes, tricyclic antidepressants, beta blockers or calcium channel blockers are often effective 5
- Vertigo associated with anxiety may respond to selective serotonin reuptake inhibitors 5
Vestibular Rehabilitation Therapy
- VRT is an exercise-based treatment program focusing on habituation, adaptation, and compensation for vestibular deficits 1
- Cawthorne-Cooksey exercises involve eye, head, and body movements in increasing difficulty to provoke vestibular symptoms 1
- For BPPV specifically, Brandt-Daroff exercises can be implemented, though they are significantly less effective than repositioning maneuvers (25% vs 80.5% resolution at 7 days) 4
- VRT is safe with no serious adverse events reported in clinical trials 1
Management of Treatment Failures
- For initial treatment failures, evaluate for persistent vertigo or underlying peripheral vestibular or CNS disorders 3
- Canal conversion occurs in approximately 6% of cases and requires appropriate repositioning for the newly affected canal 1, 4
- When symptoms are atypical or refractory to treatment, consider undiagnosed CNS disease 3
- For refractory cases of BPPV, surgical options like canal plugging may be considered, with success rates >96% 4