What are the treatment options for vertigo?

Treatment of Vertigo

The Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice for benign paroxysmal positional vertigo (BPPV), the most common cause of vertigo, with success rates of 90-98% when performed correctly. 1, 2

Diagnosis and Classification

• Vertigo should be classified based on etiology to guide appropriate treatment, with BPPV being diagnosed when characteristic nystagmus is provoked by the Dix-Hallpike maneuver (for posterior canal) or supine roll test (for lateral canal) 1, 3
• Posterior canal BPPV is the most common form, followed by lateral canal BPPV 2

Treatment Based on Specific Vertigo Type

BPPV Treatment

• For posterior canal BPPV, the Epley maneuver involves a specific sequence of head positions:
  1. Patient seated with head turned 45° toward affected ear
  2. Rapidly moved to supine position with head hanging 20° below horizontal
  3. Head turned 90° to unaffected side
  4. Head and body turned another 90° (face down)
  5. Return to sitting position 2
• For lateral canal BPPV, the Gufoni maneuver or barbecue roll maneuver should be used, with success rates of 86-100% 1, 2
• Patients should be reassessed within 1 month after treatment to confirm symptom resolution 2, 3

Vestibular Rehabilitation Therapy (VRT)

• VRT is an exercise-based treatment program focusing on habituation, adaptation, and compensation for vestibular deficits 1
• Cawthorne-Cooksey exercises, consisting of eye, head, and body movements of increasing difficulty, can provoke vestibular symptoms to force central nervous system compensation 1
• Brandt-Daroff exercises may be used but are significantly less effective than repositioning maneuvers (25% vs 80.5% resolution at 7 days) 2

Pharmacological Treatment

• Vestibular suppressant medications should NOT be routinely prescribed for BPPV as they do not address the underlying cause and may interfere with central compensation 4, 2, 3
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases, but should be used only for short-term management of severe nausea or vomiting associated with vertigo 5
• Common side effects of meclizine include drowsiness, dry mouth, and fatigue; caution is advised when driving or operating machinery 5

Treatment of Other Vestibular Causes

• For Ménière's disease, treatment includes salt restriction, diuretics, and short-term vestibular suppressants during acute attacks 3, 6
• For vestibular neuritis, brief use of vestibular suppressants followed by vestibular rehabilitation is recommended 6
• For migraine-associated vertigo, prophylactic agents such as calcium channel antagonists, tricyclic antidepressants, and beta-blockers are the mainstay of treatment 7, 6

Management of Treatment Failures

• For persistent symptoms, evaluate for:
  • Unresolved BPPV
  • Canal conversion (occurs in approximately 6% of cases)
  • Underlying peripheral vestibular or central nervous system disorders 1, 3
• For cases refractory to multiple repositioning maneuvers, surgical options like canal plugging may be considered, with success rates >96% 2

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers for BPPV 2
• Failing to reassess patients after initial treatment 2
• Missing canal conversions or multiple canal involvement 2
• Using vestibular suppressants long-term, which can delay central compensation and increase fall risk, especially in elderly patients 3