What are the treatment options for vertigo?

Treatment Options for Vertigo

The treatment of vertigo should be based on the specific underlying cause, with canalith repositioning procedures (such as the Epley maneuver) as the first-line treatment for benign paroxysmal positional vertigo (BPPV), and targeted interventions for other vestibular disorders. 1, 2

Diagnosis-Based Treatment Approaches

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) 1
• The Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice for posterior canal BPPV with success rates of 90-98% 1, 2
• For lateral canal BPPV, the Gufoni maneuver or barbecue roll maneuver has an 86-100% success rate 1, 3
• Medications are NOT recommended as primary treatment for BPPV as they do not address the underlying cause 2
• Patients should be reassessed within 1 month after initial treatment to confirm symptom resolution 1, 2

Ménière's Disease

• Treatment goals include reducing severity and frequency of vertigo attacks, relieving associated symptoms, and improving quality of life 4, 1
• Dietary modifications including salt restriction and diuretics are used to prevent flare-ups 2
• Limited course of vestibular suppressants is recommended only for acute attacks 2
• Non-ablative procedures are preferred for patients with usable hearing, while ablative treatments may be considered for patients without useful hearing 1

Medication Options

• Meclizine (25-100 mg daily in divided doses) is indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults 5
• Vestibular suppressant medications should ONLY be used for short-term management of severe symptoms rather than as definitive treatment 2
• Common side effects of meclizine include drowsiness, dry mouth, headache, fatigue, and vomiting 5
• Caution: Meclizine may cause significant adverse effects, including drowsiness and cognitive deficits that may interfere with driving or operating machinery 2, 5
• Meclizine can increase the risk of falls, especially in elderly patients 2
• Coadministration of meclizine with other CNS depressants, including alcohol, may result in increased CNS depression 5

Vestibular Rehabilitation Therapy (VRT)

• VRT is an exercise-based treatment program focusing on habituation, adaptation, and compensation for vestibular deficits 1
• Cawthorne-Cooksey exercises consist of eye, head, and body movements in increasing difficulty to provoke vestibular symptoms 1
• For BPPV specifically, Brandt-Daroff exercises involving rapid lateral head/trunk tilts can promote debris dispersion 1
• VRT is safe with no serious adverse events reported in clinical trials 1
• Home-based therapy appears equally effective as clinician-supervised therapy, though initial instruction is important 1
• VRT may be particularly beneficial for elderly patients, potentially decreasing recurrence rates of symptoms 1, 3

Treatment Based on Vertigo Type

Peripheral Vertigo (Inner Ear)

• BPPV: Canalith repositioning procedures (Epley, Semont, etc.) 1, 2, 6
• Vestibular neuritis: Brief use of vestibular suppressants is recommended 7
• Ménière's disease: Salt restriction, diuretics, and vestibular suppressants during acute attacks 2, 7

Central Vertigo (Brain-Related)

• For migraine-associated vertigo: Prophylactic agents like calcium channel antagonists, tricyclic antidepressants, and beta-blockers 7
• For structural lesions of the brainstem or cerebellum: Combination of vestibular suppressants and physical therapy 7

Psychogenic Vertigo

• Benzodiazepines may be useful for vertigo associated with anxiety disorders, panic disorder, or agoraphobia 7

Important Cautions and Considerations

• Avoid long-term use of vestibular suppressants as they can interfere with central vestibular compensation 2, 7
• Elderly patients are at higher risk for medication side effects and falls 2
• Canal conversion occurs in approximately 6% of BPPV cases and requires appropriate repositioning for the newly affected canal 1, 3
• Certain comorbidities may limit the use of repositioning maneuvers, including cervical stenosis, severe rheumatoid arthritis, and spinal cord injuries 3

Common Treatment Errors to Avoid

• Relying on medications instead of repositioning maneuvers as primary treatment for BPPV 2, 3
• Failing to reassess patients after initial treatment 2
• Overlooking canal conversions or involvement of multiple canals 3
• Using vestibular suppressants for prolonged periods, which can delay vestibular compensation 7, 8