Treatment Options for Vertigo
Primary Treatment: Canalith Repositioning Procedures for BPPV
The Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice for posterior canal BPPV, achieving 90-98% success rates and should be performed as first-line therapy rather than prescribing medications. 1, 2, 3
Specific Repositioning Techniques by Canal Involvement
Posterior canal BPPV: Perform the Epley maneuver, which involves a specific sequence: patient seated with head turned 45° toward affected ear, rapidly moved to supine with head hanging 20° below horizontal, head turned 90° to unaffected side, head and body turned another 90° face-down, then return to sitting 3
Lateral canal BPPV: Use the Gufoni maneuver or barbecue roll maneuver, which demonstrate 86-100% success rates 1, 2, 3
Post-procedure: No postprocedural restrictions are necessary after repositioning maneuvers 3
Medication Use: Limited and Specific Indications Only
Vestibular suppressant medications should NOT be routinely prescribed for BPPV treatment as they do not address the underlying cause and may impair central compensation. 1, 3
When Medications May Be Considered
Meclizine: May be used short-term (not as primary treatment) only for severe nausea or vomiting associated with vertigo, at doses of 25-100 mg daily in divided doses 1, 3, 4
Important caveat: Vestibular suppressants should be used cautiously, especially in elderly patients, due to side effects including drowsiness, cognitive deficits, and increased fall risk 1
Common pitfall to avoid: Relying on medications instead of repositioning maneuvers is inappropriate management 3
Vestibular Rehabilitation Therapy
Vestibular rehabilitation therapy should be considered for patients with persistent dizziness from vestibular causes, using progressive exercises focusing on habituation, adaptation, and compensation. 1, 2
VRT Protocol Components
Cawthorne-Cooksey exercises: Implement eye, head, and body movements in increasing difficulty, performed until symptoms fatigue to force central nervous system compensation through habituation 2
Brandt-Daroff exercises: For BPPV specifically, these involve rapid lateral head/trunk tilts to promote debris dispersion, though they are significantly less effective than repositioning procedures (25% vs 80.5% resolution at 7 days) 3
Home-based therapy: Appears equally effective as clinician-supervised therapy, though initial instruction is important 2
Treatment of Other Vestibular Conditions
Ménière's Disease
First-line approach: Salt restriction, diuretics, and short-term vestibular suppressants during acute attacks only 1
Procedural options: Non-ablative procedures are preferred for patients with usable hearing, while ablative treatments may be considered for patients without useful hearing 2
Vestibular Neuritis
Acute management: Initial stabilizing measures with vestibular suppressant medication, followed by vestibular rehabilitation exercises 5
Corticosteroids: Consider short-term steroids as a treatment option for vestibular neuritis 6
Mandatory Follow-Up and Reassessment
Patients must be reassessed within 1 month after initial treatment to document symptom resolution or identify treatment failures. 7, 1, 2, 3
Evaluation of Treatment Failures
Persistent BPPV: Repeat the Dix-Hallpike test to confirm diagnosis; if still positive, repeat repositioning maneuvers 7
Canal conversion: Occurs in approximately 6% of cases and requires examination for involvement of other semicircular canals than originally diagnosed, with appropriate repositioning for the newly affected canal 7, 2, 3
Red flags requiring neuroimaging: Patients with atypical symptoms, associated auditory or neurological symptoms, or those who fail to improve after 2-3 attempted maneuvers should undergo thorough neurological examination and MRI of the brain and posterior fossa to identify possible intracranial pathology 7
CNS disorders: Rarely, central nervous system disorders can masquerade as BPPV and were found in 3% of treatment failures in one study 7
Surgical Options for Refractory Cases
- Canal plugging: For cases refractory to multiple repositioning procedures, surgical canal plugging may be considered with success rates exceeding 96% 3
Patient Education Priorities
Recurrence rates: Counsel patients that BPPV recurs in 15% per year, with rates of 10-18% at 1 year and potentially 37-50% at 5 years 7
Safety counseling: Discuss the impact of BPPV on safety, potential for recurrence, and importance of follow-up to allow earlier recognition and treatment of recurrent episodes 7