What are the treatment options for vertigo?

Treatment of Vertigo

The Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice for the most common cause of vertigo—benign paroxysmal positional vertigo (BPPV)—with success rates of 90-98% when performed correctly, and vestibular suppressant medications should NOT be routinely used as they do not address the underlying cause. 1, 2

Diagnosis-Specific Treatment Approach

BPPV (Most Common Cause)

Posterior Canal BPPV:

• Perform the Epley maneuver as first-line treatment with the following sequence: 2
  1. Patient seated upright with head turned 45° toward affected ear
  2. Rapidly move to supine position with head hanging 20° below horizontal
  3. Turn head 90° to unaffected side
  4. Turn head and body another 90° (face down position)
  5. Return to sitting position
• Success rates reach 90-98% when performed correctly 1, 2
• No postprocedural restrictions are necessary after the maneuver 2

Lateral Canal BPPV:

• Use the Gufoni maneuver or barbecue roll maneuver as first-line treatment 1, 2
• Success rates range from 86-100% 1, 3

Alternative Exercise-Based Treatment:

• Vestibular rehabilitation therapy (VRT) may be offered as self-administered or clinician-guided exercises 2
• Brandt-Daroff exercises are significantly less effective than repositioning procedures (25% vs 80.5% resolution at 7 days) but can be used in select cases 2
• Cawthorne-Cooksey exercises involve progressive eye, head, and body movements performed until symptoms fatigue, forcing central nervous system compensation through habituation 1

Ménière's Disease

Treatment Goals:

• Reduce severity and frequency of vertigo attacks, relieve associated symptoms, and improve quality of life 1

Specific Interventions:

• Salt restriction combined with diuretics as primary management 3
• Short-term vestibular suppressants during acute attacks only 3
• Non-ablative procedures are preferred for patients with usable hearing 1
• Ablative treatments may be considered for patients without useful hearing 1

Acute Vestibular Neuronitis/Labyrinthitis

• Initial stabilizing measures with vestibular suppressant medications for symptom control 4
• Follow with vestibular rehabilitation exercises for recovery 4

Medication Use: Critical Caveats

Meclizine and Vestibular Suppressants:

• Do NOT routinely prescribe vestibular suppressants for BPPV treatment 2, 3
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases at doses of 25-100 mg daily in divided doses 5
• Consider only for short-term management of severe nausea or vomiting, not as primary treatment 2, 3
• Use cautiously in elderly patients due to drowsiness, cognitive deficits, and increased fall risk 3
• Potential anticholinergic effects require caution in patients with asthma, glaucoma, or prostate enlargement 5
• May cause CNS depression when combined with alcohol or other CNS depressants 5

Vestibular Rehabilitation Therapy (VRT)

When to Use:

• Patients with persistent dizziness from vestibular causes 3
• As adjunctive treatment for various vestibular disorders 1

Key Features:

• Exercise-based program focusing on habituation, adaptation, and compensation for vestibular deficits 1
• Safe with no serious adverse events reported in clinical trials 1
• Home-based therapy appears equally effective as clinician-supervised therapy, though initial instruction is important 1
• May be particularly beneficial for elderly patients, potentially decreasing symptom recurrence rates 1
• While initially less effective than repositioning maneuvers for BPPV, long-term effectiveness approaches that of repositioning procedures 1

Follow-Up and Management of Treatment Failures

Reassessment Timeline:

• Reassess all patients within 1 month after initial treatment to confirm symptom resolution 1, 2, 3

If Symptoms Persist:

• Reevaluate for persistent BPPV, coexisting vestibular conditions, or central nervous system disorders mimicking BPPV 2, 3
• Examine for involvement of other semicircular canals 1
• Canal conversion occurs in approximately 6% of cases and requires appropriate repositioning for the newly affected canal 1, 2

Refractory Cases:

• For cases refractory to multiple repositioning procedures, surgical options like canal plugging may be considered with success rates >96% 2

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers is the most common error 2
• Failing to reassess patients after initial treatment 2
• Missing canal conversions or multiple canal involvement 2
• Using vestibular suppressants as primary treatment for BPPV when repositioning procedures are indicated 2, 3