What is the treatment for a patient with vertigo and normal Magnetic Resonance Imaging (MRI) brain and Magnetic Resonance Angiography (MRA) head and neck?

Treatment for Vertigo with Normal MRI Brain and MRA Head and Neck

For patients with vertigo who have normal MRI brain and MRA head and neck findings, the most appropriate treatment approach depends on the specific diagnosis, with vestibular rehabilitation therapy being the cornerstone treatment for most peripheral vestibular disorders.

Diagnostic Considerations

• Vertigo with normal neuroimaging suggests peripheral vestibular disorders as the most likely cause, which can include:
  • Benign Paroxysmal Positional Vertigo (BPPV) 1
  • Vestibular neuritis/labyrinthitis 1
  • Ménière's disease 2
  • Mal de Debarquement Syndrome (MdDS) 3

Treatment Algorithm Based on Specific Diagnosis

BPPV (Brief episodic vertigo triggered by specific head movements)

• First-line treatment: Canalith repositioning procedures (e.g., Epley maneuver) with 80% success rates after 1-3 treatments 2
• No imaging is indicated unless there are atypical features such as lack of nystagmus on provoking maneuvers or lack of response to treatment 1

Vestibular Neuritis/Labyrinthitis (Acute persistent vertigo)

• Initial management: Stabilizing measures and short-term vestibular suppressant medication 4
• Follow-up treatment: Vestibular rehabilitation exercises 1, 4
• Imaging is not recommended if neurologic examination and HINTS examination are consistent with peripheral vertigo 1

Ménière's Disease (Chronic recurrent vertigo with hearing loss/tinnitus)

• Dietary modifications: Low-salt diet 2, 4
• Medication: Diuretics 4
• Vestibular suppressants: Only during acute attacks, not for long-term use 2
• MRI head and IAC without and with IV contrast and CT temporal bone without IV contrast are useful for excluding other causes 1

Mal de Debarquement Syndrome (MdDS)

• Vestibular rehabilitation therapy is recommended for chronic symptoms 5
• Avoid vestibular rehabilitation during acute symptom exacerbations 5

Medication Options

For Acute Symptomatic Relief

• Meclizine: FDA-approved for treatment of vertigo associated with diseases affecting the vestibular system in adults, dosage 25 mg to 100 mg daily in divided doses 6
• Benzodiazepines (e.g., diazepam): For short-term management of severe vertigo and associated anxiety 2
• Antiemetics (e.g., prochlorperazine): For management of severe nausea/vomiting associated with vertigo 2

Important Cautions

• Vestibular suppressants have significant side effects including drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 2
• Prolonged use of vestibular suppressants can interfere with central compensation and delay recovery 2, 7
• Benzodiazepines carry significant risk for drug dependence 2
• Anticholinergics can cause blurring of vision, dry mouth, dilated pupils, urinary retention, and sedation 2

Vestibular Rehabilitation Therapy (VRT)

• VRT is the cornerstone treatment for most peripheral vestibular disorders with normal imaging findings 7, 8
• Goals of VRT:
  • Enhance gaze stability 7
  • Improve postural stability 7
  • Reduce vertigo symptoms 7
  • Improve activities of daily living 7
• Key exercises include:
  • Head-eye movements with various body postures 7
  • Balance exercises with reduced support base 7
  • Habituation exercises (repeating movements that provoke vertigo) 7, 9
• VRT can be self-administered or directed by a physical therapist 8, 10
• Benefits typically develop over weeks of consistent practice 5

Lifestyle Modifications

• Dietary changes: Limiting salt/sodium intake, avoiding high-sugar beverages 2
• Stress management 2
• Regular exercise and adequate sleep 2
• Identifying and managing allergies (contribute to symptoms in up to 30% of Ménière's disease patients) 2

Follow-Up Recommendations

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

Common Pitfalls to Avoid

• Using vestibular suppressants long-term, which can interfere with central compensation and delay recovery 5, 2
• Expecting immediate results from vestibular rehabilitation, as benefits typically develop over weeks 5
• Misdiagnosing one vestibular disorder as another, leading to inappropriate treatment approaches 3, 5
• Recommending vestibular rehabilitation during acute vertigo attacks, which may worsen symptoms 5, 2