Treatment of Vertigo
The Canalith Repositioning Procedure (Epley maneuver) is the treatment of choice for benign paroxysmal positional vertigo (BPPV), achieving 90-98% success rates and should be performed as first-line therapy rather than prescribing medications. 1, 2
Diagnosis-Specific Treatment Algorithm
For Posterior Canal BPPV (Most Common Type)
Perform the Epley maneuver immediately upon diagnosis 1, 2:
- Patient seated with head turned 45° toward affected ear 2
- Rapidly move to supine with head hanging 20° below horizontal 2
- Turn head 90° to unaffected side 2
- Turn head and body another 90° (face down) 2
- Return to sitting 2
Critical point: Post-procedural restrictions are NOT necessary 2. This is a common misconception that should be avoided.
Reassess within 1 month to confirm resolution 2, 3. If symptoms persist after 2-3 attempted maneuvers, reevaluate for canal conversion (occurs in ~6% of cases), involvement of other canals, or CNS pathology 4, 2.
For Lateral Canal BPPV
Use the Gufoni maneuver or barbecue roll maneuver 4, 1, 2:
- Success rates range from 86-100% 1, 2
- The barbecue roll involves rolling the patient 360 degrees in a series of steps 4
For Acute Vestibular Neuronitis
Vestibular suppressants should be used only briefly 5:
- Short-term use (2-3 days maximum) to control severe symptoms 5
- Avoid benzodiazepines for routine treatment as they impede central vestibular compensation 3
- Follow with vestibular rehabilitation exercises to promote compensation 5, 6
For Ménière's Disease
Implement dietary sodium restriction plus diuretics 5, 6:
- Low-salt diet as foundational therapy 6
- Diuretics to prevent flare-ups 5
- Treatment goals include reducing attack frequency/severity and improving quality of life 1
For Vertiginous Migraine
Prophylactic medications are the mainstay 5, 6:
- L-channel calcium channel antagonists 5
- Tricyclic antidepressants 5, 6
- Beta-blockers 5, 6
- Dietary modifications 6
Role of Medications
Do NOT routinely prescribe vestibular suppressant medications for BPPV 2. This is a critical pitfall to avoid—medications should never replace repositioning maneuvers for BPPV 2.
Meclizine is FDA-approved for vertigo associated with vestibular system diseases 7:
- Dosage: 25-100 mg daily in divided doses 7
- However, use only for short-term symptom control in severe nausea/vomiting, not as primary BPPV treatment 2
- May cause drowsiness and has anticholinergic effects 7
- Can potentially impede vestibular compensation if used long-term 5
Vestibular Rehabilitation Therapy
VRT may be offered as an alternative or adjunctive treatment 4, 1, 2:
- Cawthorne-Cooksey exercises involve progressive eye, head, and body movements 1
- Brandt-Daroff exercises are significantly less effective than Epley maneuver (25% vs 80.5% resolution at 7 days) but may be used in select cases 2
- Home-based therapy is equally effective as clinician-supervised therapy 1
- Particularly beneficial for elderly patients and may decrease recurrence rates 1
- No serious adverse events reported 1
Management of Treatment Failures
If symptoms persist after initial repositioning maneuver 4, 2:
- Reevaluate for canal conversion (different canal now affected) 4, 2
- Examine for multiple canal involvement 2
- Consider coexisting vestibular conditions 2
- Obtain thorough neurological examination if symptoms are atypical or refractory after 2-3 maneuvers 4
- MRI of brain and posterior fossa if CNS pathology suspected (found in 3% of treatment failures) 4
- Surgical canal plugging for refractory cases has >96% success rate 2
Recurrence Counseling
BPPV recurs in 15% of patients per year 4:
- 10-18% recurrence at 1 year 4
- 37-50% recurrence at 5 years 4
- Post-traumatic BPPV has even higher recurrence rates 4
- Counsel patients about recurrence to enable early recognition and treatment 4