Do we always treat vertigo?

Do We Always Treat Vertigo?

No, we do not always treat vertigo—treatment depends on the specific diagnosis, symptom severity, and impact on quality of life, with some conditions like benign paroxysmal positional vertigo (BPPV) requiring active intervention while others may resolve spontaneously with observation alone.

Treatment Decision Framework

BPPV: Observation vs. Active Treatment

• Observation is an acceptable initial management strategy for BPPV in select patients, though active treatment with canalith repositioning procedures (CRP) typically provides faster symptom resolution 1.
• Spontaneous resolution occurs in a significant proportion of BPPV cases, with some studies showing up to 60% improvement in placebo groups over time 1.
• However, patients initially managed with observation who have persistent symptoms should be reassessed and offered definitive treatment with repositioning maneuvers, as these achieve 90-98% success rates with repeated attempts 1.

Ménière's Disease: Tailored Treatment Approach

• Treatment intensity should match disease severity and symptom control, with the primary goal being adequate control of vertigo episodes that significantly impact quality of life 1.
• Patients with complete vertigo control may have therapy reduced, while those with inadequate control require escalation of treatment 1.
• The natural history shows variable outcomes: some patients experience spontaneous decrease in attack frequency or complete resolution, while others worsen 1.

Vestibular Suppressant Medications: Generally Not Recommended

• Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines (e.g., meclizine) or benzodiazepines, as there is no evidence these are effective as definitive primary treatment 1.
• While meclizine is FDA-approved for vertigo associated with vestibular system diseases 2, studies show no additional benefit over placebo for BPPV when used as monotherapy 1.
• These medications may interfere with natural compensation processes and carry risks of drowsiness, falls (especially in elderly), and drug dependence 1, 3.
• Limited exceptions exist: severely symptomatic patients refusing other treatments, or prophylaxis immediately before/after CRP 1.

Vestibular Migraine: Preventive Treatment Thresholds

• First-line treatment involves lifestyle modifications (stress reduction, regular sleep, dietary changes) before pharmacological intervention 4.
• Preventive medications (beta blockers, topiramate, candesartan) are indicated when symptoms occur ≥2 days per month despite optimized acute treatment 4.
• Acute attacks may be treated with vestibular suppressants for short-term symptom relief, but not for long-term management 4.

When Treatment Is Mandatory

Treatment Failures Require Reevaluation

• Patients with persistent symptoms after initial treatment must be evaluated for unresolved disease, coexisting vestibular conditions, or serious CNS disorders masquerading as peripheral vertigo 1.
• In one study, 3% of BPPV treatment failures had underlying CNS disorders 1.
• Repeat Dix-Hallpike testing should be performed, and if positive, additional repositioning maneuvers are the treatment of choice 1.

Documentation of Outcomes Is Essential

• Clinicians should document resolution, improvement, or worsening of vertigo and quality of life changes after any treatment intervention 1.
• This ensures diagnostic accuracy, identifies treatment failures early, and prevents prolonged disability from unresolved vertigo 1.

Common Pitfalls to Avoid

• Avoid prescribing vestibular suppressants as primary BPPV treatment when repositioning maneuvers are more effective and curative 1.
• Do not continue ineffective therapy without reassessment—failure to follow up can miss serious diagnoses and prolong unnecessary suffering 1.
• Avoid long-term daily use of antivertiginous medications, as they may interfere with vestibular compensation 3.
• Do not assume all vertigo requires medication—many peripheral causes resolve spontaneously or respond better to physical maneuvers or vestibular rehabilitation 1, 5, 6.

Clinical Algorithm

1. Diagnose the specific cause of vertigo (BPPV, Ménière's, vestibular migraine, etc.) 6
2. For BPPV: Offer CRP as first-line treatment; observation acceptable only with assured follow-up 1
3. For Ménière's: Treat based on symptom severity and impact on quality of life; escalate if inadequate control 1
4. For vestibular migraine: Start lifestyle modifications; add preventive medications if symptoms ≥2 days/month 4
5. Avoid routine vestibular suppressants except in specific limited circumstances 1
6. Reassess all treatment failures within appropriate timeframes 1