What are the causes and treatment options for vertigo?

Causes and Treatment of Vertigo

Most Common Causes

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo, accounting for 42% of cases in general practice, followed by vestibular neuritis (41%) and Ménière's disease (10% in general practice, up to 43% in specialty settings). 1

Peripheral Causes (Inner Ear)

• BPPV: Brief episodes (seconds to <1 minute) of vertigo triggered by head position changes (lying down, rolling over, bending, looking up) 2, 1
• Vestibular Neuritis: Acute onset of severe, continuous vertigo lasting days to weeks without hearing loss 1, 3
• Labyrinthitis: Similar to vestibular neuritis but includes hearing loss 2, 1
• Ménière's Disease: Episodic vertigo (20 minutes to 12 hours) with fluctuating hearing loss, tinnitus, and aural fullness 2
• Perilymphatic Fistula: Abnormal connection between middle and inner ear 1
• Superior Canal Dehiscence: Abnormal opening in bone covering superior semicircular canal 1
• Ototoxic Medications: Aminoglycosides (especially gentamicin) can cause irreversible vestibular damage 1

Central Causes (Brain/Brainstem)

• Stroke/Vertebrobasilar Ischemia: May present with isolated vertigo attacks lasting minutes, often with additional neurological symptoms (dysarthria, dysphagia, diplopia, motor/sensory deficits) 2, 1
• Vestibular Migraine: Attacks lasting minutes to >24 hours, often with photophobia and migraine history 2
• Multiple Sclerosis: Progressive fluctuating bilateral hearing loss, often steroid-responsive 2
• Cerebellar Infarction: 10% can mimic peripheral vestibular disorders 1
• Vestibular Schwannoma: Chronic imbalance with asymmetric hearing loss more than episodic vertigo 2

Diagnostic Approach

Critical Distinguishing Features

Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV when vertigo with nystagmus is provoked. 2 If negative with compatible history, perform the supine roll test for lateral canal BPPV 2

Differentiate peripheral from central causes using nystagmus characteristics:

• Peripheral: Horizontal with rotatory component, unidirectional, suppressed by visual fixation, fatigable, brief latency before onset 1
• Central: Pure vertical without torsion, direction-changing without head position change, not suppressed by visual fixation, persistent 1

Red Flags Requiring Urgent Evaluation

• Downbeating nystagmus without torsional component 1
• Baseline nystagmus without provocative maneuvers 1
• New-onset severe headache with vertigo (possible vertebrobasilar stroke/hemorrhage) 1
• Additional neurological symptoms: dysarthria, dysmetria, dysphagia, motor/sensory deficits, diplopia, Horner's syndrome 1
• Failure to respond to appropriate peripheral vertigo treatments 1

Testing Recommendations

Do NOT routinely order radiographic imaging or vestibular testing in patients with diagnosed BPPV unless the diagnosis is uncertain or additional symptoms unrelated to BPPV are present. 2

Treatment

BPPV Treatment

Treat posterior canal BPPV with particle repositioning maneuvers (PRM), also called canalith repositioning procedures (CRP), such as the Epley maneuver. 2 Success rates reach 90-98% when additional repositioning maneuvers are performed for treatment failures 2

Treatment options in order of preference:

1. Canalith repositioning procedures (first-line) 2
2. Vestibular rehabilitation (self-administered or clinician-guided) as alternative initial treatment 2
3. Observation with assured follow-up (acceptable for initial management) 2

For lateral canal BPPV: Cure rates of 86-100% with up to 4 CRP treatments, though the apogeotropic variant may be more refractory 2

Vestibular Neuritis/Labyrinthitis Treatment

• Initial vestibular suppressant medications followed by vestibular rehabilitation exercises 4, 5
• Symptoms typically improve over days to weeks 1

Ménière's Disease Treatment

• Low-salt diet combined with diuretics 4, 5
• Episodes last 20 minutes to 12 hours 2

Vestibular Migraine Treatment

• Dietary modifications, tricyclic antidepressants, beta blockers, or calcium channel blockers 4

Medication Considerations

Do NOT routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. 2

Meclizine (25-100 mg daily in divided doses) is FDA-approved for vertigo associated with vestibular system diseases but should be used with caution: 6

• May cause drowsiness affecting ability to drive or operate machinery 6
• Use carefully in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 6
• Can increase CNS depression when combined with alcohol or other CNS depressants 6

Follow-Up and Treatment Failures

Reassess patients within 1 month after initial observation or treatment to confirm symptom resolution. 2

For treatment failures with persistent symptoms:

• Repeat Dix-Hallpike test to confirm persistent BPPV 2
• If positive, perform additional repositioning maneuvers 2
• Evaluate for coexisting vestibular conditions or serious CNS disorders that may simulate BPPV 2
• For refractory cases after multiple CRPs, surgical plugging of the involved semicircular canal or singular neurectomy has >96% success rate 2

Common Pitfalls to Avoid

• Missing central causes: 10% of cerebellar strokes present similarly to peripheral vestibular disorders 1
• Overlooking subtle neurological signs indicating central pathology 1
• Ignoring medication side effects from vestibulotoxic agents 1
• Ordering unnecessary imaging/testing for straightforward BPPV 2
• Using vestibular suppressants as primary BPPV treatment instead of repositioning maneuvers 2