What is the recommended management for acute vertigo?

Management for Acute Vertigo

For acute vertigo, a limited course of vestibular suppressants should be used for short-term symptomatic relief while addressing the underlying cause, with canalith repositioning maneuvers being first-line for BPPV and lifestyle modifications for Ménière's disease. 1, 2

Diagnosis-Based Treatment Approach

• For BPPV (characterized by brief, positional vertigo):

  • Canalith repositioning procedures are first-line with 80% success rates after 1-3 treatments 2
  • Medications are not recommended as primary treatment as they don't address the underlying cause 3, 2
  • Vestibular suppressants may interfere with recovery and should be avoided unless managing severe autonomic symptoms 3

• For Ménière's disease and other non-BPPV peripheral vertigo:

  • Limited course of vestibular suppressants only during acute attacks 3, 1
  • Dietary modifications (salt restriction) and lifestyle changes for prevention 3, 2

Medication Options for Acute Symptomatic Relief

• Meclizine (25-100 mg daily in divided doses) is the most commonly used antihistamine for peripheral vertigo 1, 4

  • Should be used primarily as-needed rather than scheduled to avoid interfering with vestibular compensation 1
  • FDA-approved for treatment of vertigo associated with vestibular system diseases 4

• Benzodiazepines (e.g., diazepam) may be used for short-term management of severe vertigo 3, 1

  • Can help with psychological anxiety secondary to vertigo 3
  • Studies show equal effectiveness to meclizine for acute vertigo treatment 5

• Antiemetics for severe nausea/vomiting:

  • Prochlorperazine for short-term management of severe nausea/vomiting 1
  • Scopolamine (transdermal) primarily for motion sickness rather than other forms of vertigo 6

Important Cautions and Considerations

• Vestibular suppressants have significant side effects 3, 1:

  • Drowsiness, cognitive deficits, interference with driving 1, 4
  • Increased fall risk, especially in elderly patients 3, 2
  • Potential for polypharmacy issues 3

• Prolonged use of vestibular suppressants can 1, 7:

  • Interfere with central compensation in peripheral vestibular conditions
  • Delay recovery and rehabilitation

• Meclizine specifically has contraindications 4:

  • Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects
  • Avoid alcohol while taking meclizine due to increased CNS depression

Lifestyle Modifications

• For Ménière's disease and other forms of vertigo 3, 2:
  • Limit salt/sodium intake
  • Avoid excessive caffeine, alcohol, and nicotine
  • Maintain adequate hydration and regular exercise
  • Get sufficient sleep
  • Manage stress appropriately

Follow-Up and Long-Term Management

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 3, 2
• Transition from medication to vestibular rehabilitation when appropriate to promote long-term recovery 1, 8
• Vestibular rehabilitation is recommended for chronic imbalance but not for acute vertigo attacks in Ménière's disease 3

Specific Treatment Algorithms

• For acute severe vertigo:

  • Start with meclizine 25-50 mg orally for immediate symptom relief 1, 4
  • Add prochlorperazine for severe nausea/vomiting 1
  • Consider benzodiazepines for severe anxiety component 3, 1
  • Position patient on healthy side with head and trunk raised 20 degrees 9
  • Discontinue vestibular suppressants as soon as possible to avoid interfering with compensation 1, 7

• For BPPV specifically:

  • Perform appropriate canalith repositioning maneuver based on canal involvement 3, 2
  • Avoid vestibular suppressants as primary treatment 3, 2
  • Use medications only for severe autonomic symptoms or as prophylaxis for patients with severe nausea during repositioning maneuvers 3