What is the management of vertigo?

Management of Vertigo

The management of vertigo depends critically on accurate diagnosis, with canalith repositioning procedures (CRP) as first-line treatment for BPPV, vestibular suppressant medications reserved only for short-term symptom control in severe cases, and vestibular rehabilitation for persistent symptoms—while avoiding routine use of antihistamines or benzodiazepines that interfere with central compensation. 1, 2

Initial Diagnostic Approach

The first step is determining whether vertigo is triggered by specific head movements, which strongly suggests BPPV 1. Key historical features to elicit include:

• Positional triggers: Lying down, rolling over in bed, bending forward, or tilting the head back 3
• Associated symptoms: Hearing loss or tinnitus (suggests Ménière's disease or other peripheral causes), neurological symptoms (suggests central causes), or migraine features 3
• Duration of episodes: Seconds to minutes (BPPV), minutes to hours (Ménière's or vestibular migraine), or continuous (vestibular neuritis or central causes) 3

Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV by observing for characteristic torsional, upbeating nystagmus 1. If negative but history suggests BPPV, perform the supine roll test to assess for lateral canal BPPV 1.

Distinguishing Peripheral from Central Causes

Central causes require urgent evaluation and have distinct nystagmus patterns 3:

• Red flag nystagmus findings: Downbeating nystagmus on Dix-Hallpike (especially without torsional component), direction-changing nystagmus without head position changes, gaze-evoked nystagmus, or direction-switching nystagmus 3
• Associated neurological signs: Dysarthria, dysmetria, dysphagia, sensory or motor deficits, or Horner's syndrome suggest brainstem or cerebellar stroke 3
• Vestibular migraine criteria: ≥5 episodes lasting 5 minutes to 72 hours, migraine history, and migraine symptoms during ≥50% of dizzy episodes 3

Treatment Based on Diagnosis

BPPV (Most Common Cause)

Canalith repositioning procedures are the treatment of choice for posterior canal BPPV, with the Epley maneuver achieving 90-98% success rates when performed correctly 1, 2. This is vastly superior to observation alone or medication 2.

Treatment algorithm for BPPV:

• First-line: Perform CRP (Epley maneuver for posterior canal, appropriate maneuver for lateral canal) 1
• Treatment failures (15-50% after single session): Repeat the Dix-Hallpike test to confirm persistent BPPV, then perform additional CRP—success rates reach 90-98% with repeated procedures 3, 1
• Persistent failures: Consider canal conversion (posterior to lateral or vice versa in ~6% of cases), involvement of multiple canals simultaneously, or misdiagnosis of the involved canal 3
• Refractory cases: Surgical plugging of the involved semicircular canal or singular neurectomy has >96% success rate but is reserved for cases failing multiple CRP attempts 3

Observation is an option for posterior canal BPPV, with spontaneous resolution occurring at a mean of 39 days, but patients experience longer symptom duration and potentially higher recurrence rates compared to CRP 3.

Medication Management: When and What to Use

Vestibular suppressant medications should NOT be used routinely for BPPV or as primary treatment for vertigo 3, 2. The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine treatment with antihistamines or benzodiazepines 3, 2.

Limited appropriate uses for medications:

• Severe nausea/vomiting: Prochlorperazine 5-10 mg orally or IV (maximum 3 doses per 24 hours) for short-term symptom control only 2, 4
• Severe acute vertigo symptoms: Meclizine 25-100 mg daily in divided doses (FDA-approved for vertigo associated with vestibular system diseases) as needed, not scheduled 5
• Acute vestibular neuritis: Short-term vestibular suppressants during the acute phase only, followed by early vestibular rehabilitation 4
• Ménière's disease attacks: Limited course of vestibular suppressants only during acute attacks, not as continuous therapy 4

Critical cautions about vestibular suppressants:

• Interfere with central compensation in peripheral vestibular conditions when used long-term 3, 4
• Significant fall risk, especially in elderly patients—vestibular suppressants are an independent risk factor for falls 2, 4
• Side effects: Drowsiness, cognitive deficits, interference with driving and operating machinery 2, 5
• Decreased diagnostic sensitivity during Dix-Hallpike maneuvers due to vestibular suppression 2

Vestibular Rehabilitation

Vestibular rehabilitation is indicated for:

• Persistent symptoms after CRP for BPPV 3
• Vestibular neuritis or labyrinthitis after acute phase 4
• Chronic vestibular hypofunction 6

Early initiation of vestibular exercises ensures more rapid return to normal physical activity 7.

Assessment of Modifying Factors

Evaluate all patients with vertigo for factors that modify management 3:

• Fall risk assessment: Elderly patients have 12-fold increased fall risk when symptomatic with dizziness 3. Ask: (1) Have you fallen in the past year? (2) Do you feel unsteady? (3) Do you worry about falling? 3
• Comorbidities: Diabetes, hypertension, migraine, anxiety, and history of stroke or head trauma are more common in BPPV patients and may affect treatment outcomes 3
• Posttraumatic BPPV: Requires repeated CRP in up to 67% of cases compared to 14% for nontraumatic forms 3
• Impaired mobility or balance, CNS disorders, lack of home support: These factors necessitate closer monitoring and potentially modified treatment approaches 3

Reassessment and Follow-up

Reassess all patients within 1 month after initial treatment to confirm symptom resolution 1, 4. For treatment failures, the systematic approach includes:

1. Confirm persistent positional vertigo with history of symptoms provoked by positional changes 3
2. Repeat Dix-Hallpike or supine roll test to confirm persistent BPPV 3
3. Consider alternative diagnoses: CNS disorders can masquerade as BPPV, particularly in treatment failures 3
4. Perform additional CRP if BPPV confirmed 3, 1
5. Consider MRI brain with contrast if atypical nystagmus patterns, neurological symptoms present, or failure to respond to appropriate treatment 1

Imaging Considerations

Imaging is NOT recommended for typical BPPV with a positive Dix-Hallpike test 1.

MRI brain with contrast is indicated when:

• Vertigo presents with additional neurological symptoms 1
• Atypical nystagmus patterns are observed 1
• Patient fails to respond to appropriate treatment 1

Patient Education

Counsel patients about:

• Recurrence risk: BPPV can recur, and patients should recognize symptoms for early re-treatment 1
• Fall precautions: Especially critical in elderly patients—avoid activities requiring balance during symptomatic periods 3, 1
• Lifestyle modifications: For Ménière's disease or vestibular migraine, limit salt/sodium intake, avoid excessive caffeine, alcohol, and nicotine, maintain adequate hydration, regular exercise, and sufficient sleep 4
• Avoid driving or operating machinery if taking vestibular suppressants 5