What is the initial treatment approach for a patient experiencing vertigo?

Initial Treatment Approach for Vertigo

The initial treatment for vertigo should be a canalith repositioning procedure (CRP), specifically the Epley maneuver, for patients diagnosed with benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo. 1, 2

Diagnostic Approach

• Diagnosis should be based on the pattern of vertigo and appropriate diagnostic maneuvers 1:
  • For posterior canal BPPV: Perform the Dix-Hallpike maneuver (positive when vertigo with torsional, upbeating nystagmus is provoked) 1
  • For lateral canal BPPV: Perform the supine roll test if Dix-Hallpike is negative or shows horizontal nystagmus 1

Treatment Algorithm Based on Vertigo Type

For BPPV (most common cause):

1. First-line treatment: Canalith Repositioning Procedure 1, 2

   • Posterior canal BPPV: Epley maneuver (success rates of 90-98% when performed correctly) 1, 2
   • Lateral canal BPPV: Gufoni maneuver or barbecue roll maneuver (86-100% success rate) 2

2. Alternative/adjunctive options:

   • Vestibular rehabilitation therapy (VRT) - may be self-administered or clinician-directed 2
   • Observation with follow-up (spontaneous resolution may occur, but less effective than CRP) 1

3. NOT recommended initially:

   • Vestibular suppressant medications should NOT be routinely prescribed 1
   • Postprocedural restrictions after CRP are NOT necessary 1

For Acute Vestibular Syndrome (continuous vertigo lasting days):

• Position patient on their healthy side with head and trunk raised 20 degrees 3
• Vestibular suppressants may be used short-term for symptom control:
  • Meclizine 25-100 mg daily in divided doses 4
  • Diazepam may be used for severe symptoms 3

Follow-up and Management of Treatment Failure

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 1, 2
• For persistent symptoms, evaluate for:
  • Unresolved BPPV (may require repeat CRP) 1
  • Involvement of other semicircular canals (canal conversion occurs in ~6% of cases) 2
  • Underlying peripheral vestibular or central nervous system disorders 1

Important Cautions

• Avoid vestibular suppressant medications like antihistamines and benzodiazepines as routine first-line treatment for BPPV 1
• Meclizine may cause drowsiness; patients should be warned against driving or operating dangerous machinery and should avoid alcohol 4
• Use meclizine with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 4
• Consider central causes of vertigo (requiring neuroimaging) if:
  • Symptoms are atypical or refractory to treatment 1
  • Associated neurological symptoms are present 1
  • Treatment failure occurs after 2-3 properly performed repositioning maneuvers 1

Special Considerations

• Elderly patients may benefit particularly from vestibular rehabilitation therapy to decrease recurrence rates 2
• For Ménière's disease, consider low-salt diet and diuretics as initial treatment 5
• For vertiginous migraine, dietary changes and prophylactic medications may be effective 5

Remember that the success rate of BPPV treatment reaches 90-98% when repositioning maneuvers are performed correctly, making this the clear first choice for initial management 1, 2.