What is the first line of treatment for acute peripheral vertigo?

First-Line Treatment for Acute Peripheral Vertigo

The first-line treatment for acute peripheral vertigo depends critically on the underlying cause: for BPPV (the most common cause), canalith repositioning procedures like the Epley maneuver are first-line with 80% success rates, while for acute vestibular neuritis or Ménière's disease attacks, short-term vestibular suppressants (meclizine 25-100 mg daily) provide symptomatic relief but should be discontinued quickly to avoid delaying vestibular compensation. 1, 2

Diagnostic Algorithm to Guide Treatment

Step 1: Identify the Specific Cause

BPPV (Most Common)

• Characterized by brief (seconds to minutes) episodes of intense vertigo triggered by specific head position changes 1
• Positive Dix-Hallpike maneuver confirms diagnosis 3
• First-line treatment: Canalith repositioning procedures (Epley or Semont maneuver), NOT medications 3, 1
• Success rate of approximately 80% with only 1-3 treatments 1

Acute Vestibular Neuritis/Labyrinthitis

• Sudden onset of continuous severe vertigo lasting hours to days 4
• No hearing loss (vestibular neuritis) or with hearing loss (labyrinthitis) 5
• First-line treatment: Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) for 2-3 days maximum 2, 4, 6
• Must withdraw suppressants quickly to avoid impeding central vestibular compensation 4

Ménière's Disease

• Episodic vertigo attacks lasting 20 minutes to hours with hearing loss, tinnitus, and aural fullness 2
• First-line for acute attacks: Limited course of vestibular suppressants (meclizine) only during attacks 1, 2
• First-line for prevention: Salt restriction (<1500-2000 mg/day) and diuretics 1, 7

Medication Guidelines When Indicated

Meclizine (When Appropriate)

• Dosage: 25-100 mg daily in divided doses 6
• Use as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 1, 2
• Works by suppressing the central emetic center 2

Critical Cautions About Vestibular Suppressants

• Should NEVER be used routinely for BPPV - studies show 78.6-93.3% improvement with repositioning maneuvers versus only 30.8% with medication alone 3, 1
• Can cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk especially in elderly patients 3, 1, 4
• Long-term use interferes with central vestibular compensation 2, 4
• Patients who underwent Epley maneuver alone recovered faster than those receiving concurrent vestibular suppressants 3, 1

Adjunctive Medications for Severe Symptoms

• Prochlorperazine: For severe nausea/vomiting, 5-10 mg orally or IV, maximum three doses per 24 hours 2
• Benzodiazepines: May help with severe symptoms and psychological anxiety, but use short-term only 3, 2

Common Pitfalls to Avoid

Pitfall #1: Prescribing meclizine for BPPV

• This is explicitly recommended against by guidelines 3, 1
• Delays definitive treatment and exposes patients to unnecessary side effects 3
• Exception: May use briefly for severe nausea during repositioning procedures 1

Pitfall #2: Prolonged vestibular suppressant use

• Delays central compensation and prolongs recovery 2, 4
• Should be withdrawn as soon as possible, typically within 2-3 days 4

Pitfall #3: Using vestibular suppressants in elderly patients without careful consideration

• Significantly increases fall risk 1, 4
• Anticholinergic burden causes cognitive deficits, dry mouth, blurred vision, urinary retention 1

Follow-Up Requirements

• Reassess all patients within 1 month after initial treatment to confirm symptom resolution 3, 2, 4
• Failure to respond suggests either incorrect diagnosis (1.1-3% of "BPPV" cases are actually CNS lesions) or need for alternative treatment 3
• Transition from medications to vestibular rehabilitation exercises when appropriate to promote long-term recovery 2, 4

Lifestyle Modifications (Adjunctive)

• For Ménière's disease: Limit salt/sodium intake, avoid excessive caffeine, alcohol, and nicotine 1, 2
• Maintain adequate hydration, regular exercise, and sufficient sleep 1
• Manage stress appropriately 1, 2