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 (BPPB), with success rates of 90-98% when performed correctly. 1

Diagnosis-Based Treatment Approach

Benign Paroxysmal Positional Vertigo (BPPV)

• 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) 2, 3
• First-line treatment for posterior canal BPPV is the Canalith Repositioning Procedure (Epley maneuver) 1, 3
• For lateral canal BPPV, the Gufoni maneuver or barbecue roll maneuver is recommended with success rates of 86-100% 1, 3
• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 2, 1
• 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 3, 4

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 as maintenance therapy to reduce symptoms or prevent attacks 2
• Intratympanic steroids may be offered to patients with active Ménière's disease not responsive to noninvasive treatment 2
• Non-ablative procedures are preferred for patients with usable hearing, while ablative treatments may be considered for patients without useful hearing 1
• Positive pressure therapy should not be prescribed to patients with Ménière's disease 2

Pharmacological Management

• Meclizine is FDA-approved for the treatment of vertigo associated with diseases affecting the vestibular system in adults 4
• Recommended dosage of meclizine is 25 mg to 100 mg daily, in divided doses 4
• Caution should be exercised when prescribing meclizine due to potential side effects including drowsiness, dry mouth, and blurred vision 4
• Meclizine should be prescribed with care to patients with a history of asthma, glaucoma, or enlargement of the prostate gland due to potential anticholinergic effects 4
• Coadministration of meclizine with other CNS depressants, including alcohol, may result in increased CNS depression 4

Vestibular Rehabilitation Therapy (VRT)

• VRT is an exercise-based treatment program focusing on habituation, adaptation, and compensation for vestibular deficits 1
• VRT should not be recommended for managing acute vertigo attacks in patients with Ménière's disease 2
• VRT may be beneficial for chronic imbalance and can be implemented as a series of progressive exercises 1
• Cawthorne-Cooksey exercises, consisting of eye, head, and body movements in increasing difficulty, can be implemented to provoke vestibular symptoms 1
• Home-based therapy appears equally effective as clinician-supervised therapy, though initial instruction is important 1

Management of Treatment Failures

• Patients with persistent symptoms should be evaluated for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders 2, 3
• Canal conversion occurs in approximately 6% of cases and requires appropriate repositioning for the newly affected canal 1, 3
• For cases refractory to multiple repositioning maneuvers, surgical options like canal plugging may be considered, with success rates >96% 3

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers for BPPV treatment 3, 5
• Failing to reassess patients after initial treatment 2, 3
• Missing canal conversions or multiple canal involvement 3
• Prolonged use of vestibular suppressant medications, which can delay central compensation and increase risk of falls, especially in elderly patients 6, 5