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%, and vestibular suppressant medications should NOT be routinely used. 1, 2

Diagnosis-Driven Treatment Algorithm

For BPPV (Most Common Cause)

First-line treatment is the Epley maneuver for posterior canal BPPV, which involves a specific sequence: patient seated with head turned 45° toward affected ear, rapidly moved to supine with head hanging 20° below horizontal, head turned 90° to unaffected side, head and body turned another 90° face-down, then return to sitting. 2

• For lateral canal BPPV, use the Gufoni maneuver or barbecue roll maneuver with success rates of 86-100%. 1, 2
• Do NOT prescribe vestibular suppressants routinely—they are ineffective for BPPV and may decrease diagnostic sensitivity during Dix-Hallpike testing. 3, 2
• Meclizine may be considered only for short-term management of severe nausea or vomiting, not as primary treatment. 2, 4
• No postprocedural restrictions are necessary after repositioning maneuvers. 2
• Reassess within 1 month to document symptom resolution. 3, 1

For Vestibular Neuronitis/Labyrinthitis

Use vestibular suppressants only briefly during the acute phase, followed by vestibular rehabilitation exercises. 5

• Acute management options include diazepam 10 mg IM once or twice daily to decrease internuclear inhibition, or gabapentin 300 mg PO 2-3 times daily to reduce nystagmus and stabilize visual field. 6
• Prolonged use of vestibular suppressants should be avoided as they may impair central compensation. 7
• Vestibular rehabilitation therapy should be initiated after acute symptoms subside. 1

For Ménière's Disease

Treatment goals include reducing severity and frequency of vertigo attacks, relieving associated symptoms, and improving quality of life. 1

• Salt restriction and diuretics are first-line preventive measures. 8, 7
• Short-term vestibular suppressants during acute attacks only. 8, 7
• Non-ablative procedures are preferred for patients with usable hearing. 1

For Vestibular Migraine

Prophylactic agents are the mainstay of treatment, including calcium channel antagonists, tricyclic antidepressants, and beta-blockers. 7

• Dietary modifications should be implemented. 5

Vestibular Rehabilitation Therapy

Offer vestibular rehabilitation as an option for patients with additional impairments, those who fail initial repositioning attempts, those not candidates for repositioning, or those who refuse it. 3

• Cawthorne-Cooksey exercises involve progressive eye, head, and body movements performed until symptoms fatigue, forcing central nervous system compensation through habituation. 1
• Home-based therapy is equally effective as clinician-supervised therapy, though initial instruction is important. 1
• VRT is safe with no serious adverse events reported in clinical trials. 1
• For BPPV, Brandt-Daroff exercises are significantly less effective than repositioning procedures (25% vs 80.5% resolution at 7 days) but may be used as an alternative. 2

Management of Treatment Failures

If symptoms persist after initial treatment, reevaluate for:

• Persistent BPPV in the same canal. 2, 8
• Canal conversion (occurs in approximately 6% of cases) requiring repositioning for the newly affected canal. 1, 2
• Multiple canal involvement. 1
• Coexisting vestibular conditions or central nervous system disorders mimicking BPPV. 2, 8

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

Critical Pitfalls to Avoid

Relying on medications instead of repositioning maneuvers is the most common error in BPPV management. 2

• Vestibular suppressants like antihistamines and benzodiazepines have potentially harmful side effects including drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients. 3, 8
• Failing to reassess patients after initial treatment misses opportunities for retreatment or diagnosis of alternative conditions. 2
• Missing canal conversions or multiple canal involvement leads to treatment failure. 2
• The American Academy of Otolaryngology-Head and Neck Surgery recognizes a very small subgroup of severely symptomatic patients may need vestibular suppression until definitive treatment can be offered, but this is the exception, not the rule. 3