What is the recommended treatment for acute vertigo in Canada?

Treatment for Acute Vertigo in Canada

For acute vertigo management in Canada, a limited course of vestibular suppressants is recommended only during acute vertigo attacks, with medication choice based on the underlying cause of vertigo. 1, 2

Diagnosis-Based Treatment Approach

• Canalith repositioning procedures are first-line treatment for Benign Paroxysmal Positional Vertigo (BPPV) with 80% success rates after 1-3 treatments 1
• For Ménière's disease and other non-BPPV peripheral vertigo, vestibular suppressants should be used only during acute attacks 1, 3
• Medications are not recommended as primary treatment for BPPV as they don't address the underlying cause 2

Medication Options for Acute Symptomatic Relief

• Antihistamines:

  • Meclizine is the most commonly used antihistamine for peripheral vertigo and should be used primarily as-needed rather than scheduled to avoid interfering with vestibular compensation 2, 3
  • Dimenhydrinate is an alternative antihistamine option available in Canada 4

• Benzodiazepines:

  • May be used for short-term management of severe vertigo and can help with psychological anxiety secondary to vertigo 1, 3
  • Examples include diazepam, which can be administered 10 mg once or twice a day for acute symptoms 5
  • All benzodiazepines carry significant risk for drug dependence 6

• Anticholinergics:

  • Scopolamine (available in transdermal formulation) and atropine can suppress acute vertigo attacks 6, 1
  • These medications can cause blurring of vision, dry mouth, dilated pupils, urinary retention, and sedation 6

• Antiemetics:

  • Prochlorperazine may be used for short-term management of severe nausea/vomiting associated with vertigo 1, 3
  • Other options include metoclopramide 10 mg once or twice a day or triethylperazine rectally 5

• Other options:

  • Cinnarizine (often combined with dimenhydrinate) has shown efficacy for acute vestibular vertigo 4, 7
  • For vestibular migraine, triptans are usually tried first for acute attacks 8

Important Cautions and Considerations

• Vestibular suppressants have significant side effects, including drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 1, 2
• Prolonged use of vestibular suppressants can interfere with central compensation in peripheral vestibular conditions and delay recovery 1, 2, 3
• Anticholinergics should be used with caution due to their significant side effect profile and potential for toxicity 6
• Vestibular rehabilitation is recommended for chronic imbalance but not for acute vertigo attacks in Ménière's disease 1, 2

Lifestyle Modifications for Symptom Prevention

• Limit salt/sodium intake in the diet 6, 1
• Avoid excessive caffeine, alcohol, and nicotine 6, 2
• Maintain adequate hydration throughout the day 6, 3
• Manage stress appropriately through relaxation techniques 6, 1
• Get regular exercise and adequate sleep 6, 3
• Identify and manage any allergies, which can contribute to symptoms of Ménière's disease in up to 30% of patients 6, 1

Follow-Up and Long-Term Management

• Patients should be reassessed within 1 month after initial treatment to document resolution or persistence of symptoms 1, 2
• Transition from medication to vestibular rehabilitation when appropriate to promote long-term recovery 1, 3
• For patients with increased bouts of vertigo, assessment for sleep apnea should be considered 6

Practical Management Algorithm

1. Identify vertigo type (BPPV, Ménière's, vestibular neuritis, or other)
2. For BPPV: Perform canalith repositioning maneuvers; avoid medications 1, 2
3. For non-BPPV vertigo during acute attacks:
   • First-line: Meclizine as needed for symptom control 2, 3
   • For severe symptoms: Add benzodiazepines short-term 1, 3
   • For severe nausea: Add antiemetic such as prochlorperazine 1, 3
4. Limit medication use to acute attack periods only 6, 1
5. Implement lifestyle modifications to prevent recurrence 6, 2
6. Follow up within one month to assess response and adjust treatment 1, 2