What are the treatment options for managing vertigo?

Management of Vertigo

First-Line Treatment Based on Etiology

The management of vertigo depends critically on identifying the underlying cause, with particle repositioning maneuvers being the definitive treatment for BPPV (the most common cause), while vestibular suppressant medications should be avoided as routine therapy and reserved only for short-term symptomatic relief in specific non-BPPV conditions. 1, 2

Diagnostic Framework: Identify the Cause First

Before treating vertigo, distinguish between the major causes using clinical examination:

• BPPV (most common): Brief episodes (seconds to minutes) triggered by head position changes; diagnose with Dix-Hallpike maneuver for posterior canal or supine roll test for lateral canal 1, 2
• Vestibular neuronitis/labyrinthitis: Prolonged spontaneous vertigo lasting hours to days without positional triggers 3, 4
• Ménière's disease: Episodic vertigo (20 minutes to hours) with hearing loss, tinnitus, and aural fullness 1
• Central causes: Require immediate evaluation if neurological signs present (diplopia, dysarthria, ataxia, focal weakness) 4, 5

Treatment Algorithm by Diagnosis

For BPPV (Posterior Canal - Most Common)

Perform particle repositioning maneuver (Epley maneuver) as first-line treatment with 80-93% success rates after 1-3 treatments. 1, 2

• Do NOT use vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment - they do not address the underlying cause and have significantly lower efficacy (30.8% vs 78.6-93.3% for repositioning maneuvers) 1, 2
• Meclizine may only be considered for severe nausea/vomiting during the maneuver itself or in patients who refuse repositioning 2
• Reassess within 1 month to confirm symptom resolution 1, 6
• If symptoms persist, evaluate for persistent BPPV, canal conversion, or alternative diagnoses 1, 6

For BPPV (Lateral Canal)

• Perform Gufoni maneuver or barbecue roll maneuver with 86-100% success rates 6
• Same medication avoidance principles apply as for posterior canal BPPV 2, 6

For Ménière's Disease

Implement dietary sodium restriction (1500-2300 mg daily) combined with diuretics as first-line preventive therapy. 1, 2

• For acute vertigo attacks: Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) for symptom control only 1, 2, 7
• Limit alcohol and caffeine intake 1, 2
• Consider betahistine (histamine analogue) to increase inner ear vasodilation 1
• For refractory cases: Middle ear steroid or gentamicin injections, or surgical options (endolymphatic sac decompression, vestibular nerve section) 1

For Acute Vestibular Neuronitis/Labyrinthitis

• Short-term vestibular suppressants (3-5 days maximum) for severe acute symptoms 3, 8
• Transition to vestibular rehabilitation exercises as soon as tolerated to promote central compensation 3, 8, 5
• Avoid prolonged medication use as it interferes with natural vestibular compensation 8

Medication Guidelines and Critical Warnings

When Vestibular Suppressants May Be Used (Limited Circumstances)

• Meclizine 25-100 mg daily in divided doses: Use as-needed rather than scheduled to avoid interfering with vestibular compensation 2, 7
• Only for: Acute severe symptoms in vestibular neuronitis, Ménière's attacks, or severe nausea during repositioning maneuvers 2, 7
• Duration: Maximum 3-5 days; discontinue as soon as possible 2, 8

Critical Contraindications and Warnings

Vestibular suppressants cause significant adverse effects, particularly in elderly patients, including drowsiness, cognitive deficits, anticholinergic effects, and dramatically increased fall risk. 2, 6, 7

• Elderly patients: High risk for falls, injuries, and anticholinergic burden (dry mouth, urinary retention, confusion) 2, 7
• Avoid in: Patients with asthma, glaucoma, or prostate enlargement 7
• Drug interactions: Increased CNS depression with alcohol and other CNS depressants; potential interactions with CYP2D6 inhibitors 7
• Driving impairment: Warn patients about drowsiness affecting ability to operate machinery 2, 7

Vestibular Rehabilitation

• Indicated for: Persistent dizziness from any vestibular cause, chronic imbalance, or incomplete recovery 2, 6, 5
• Can be self-administered or therapist-directed 1, 5
• Promotes central nervous system compensation for vestibular deficits 3, 5

Testing and Imaging: When NOT to Order

Do NOT routinely order radiographic imaging (CT/MRI) or vestibular testing in patients with diagnosed BPPV unless the diagnosis is uncertain or additional non-BPPV symptoms are present. 1

• Audiometry may be indicated for Ménière's disease to document hearing loss 1
• MRI indicated only if central causes suspected (neurological signs, atypical features) 1, 4

Follow-Up Protocol

• Reassess all patients within 1 month after initial treatment to document resolution or persistence 1, 2, 6
• For treatment failures: Re-evaluate for correct diagnosis, perform repeat repositioning if BPPV, or investigate for central/peripheral vestibular disorders 1, 6
• Counsel patients on fall risk, potential recurrence, and importance of follow-up 1

Common Pitfalls to Avoid

• Never prescribe meclizine as primary treatment for BPPV - this is the most common error and delays definitive cure 1, 2
• Never use vestibular suppressants long-term - they prevent natural compensation and increase fall risk 2, 8
• Never assume all positional vertigo is benign - perform proper diagnostic maneuvers to confirm BPPV 1
• Never skip reassessment - 20-30% of BPPV cases require repeat treatment 1, 2