What is the management approach for intractable vertigo?

Management of Intractable Vertigo

For intractable vertigo that fails initial repositioning maneuvers, escalate systematically: first reassess for persistent BPPV or alternative canal involvement, then consider vestibular rehabilitation therapy, and reserve ablative interventions (transtympanic gentamicin or surgical canal plugging) only for severe cases unresponsive to all conservative measures. 1, 2, 3

Initial Reassessment of Treatment Failures

When vertigo persists despite initial treatment, the critical first step is reevaluation rather than escalation:

• Evaluate for persistent BPPV or underlying peripheral vestibular/CNS disorders within 1 month of initial treatment to confirm whether symptoms have resolved 1, 2
• Assess for canal conversion, which occurs in approximately 6% of cases and requires repositioning for the newly affected canal 2
• Examine for multiple canal involvement, as this is a common cause of treatment failure and requires sequential treatment of each affected canal 4
• Rule out central causes mimicking peripheral vertigo (central positional paroxysmal vertigo), particularly in patients with atypical Dix-Hallpike findings or lack of response to repositioning 1

Etiology-Specific Management

For Intractable BPPV

• Repeat canalith repositioning procedures (Epley maneuver for posterior canal, Gufoni or barbecue roll for lateral canal) as first-line, given 90-98% success rates when performed correctly 2, 4
• Consider chair-assisted treatment if available and standard maneuvers have failed 4
• Reserve surgical canal plugging exclusively for same-canal, same-side intractable severe BPPV that has failed all other interventions 4

For Intractable Ménière's Disease

• Implement dietary modifications including salt/sodium restriction, avoiding excessive caffeine, alcohol, and nicotine, with adequate hydration 5
• Prescribe diuretics in combination with low-salt diet for vertigo attack prevention 6, 7
• Consider transtympanic corticosteroid injections for patients not benefiting from conservative therapy 3
• Reserve transtympanic gentamicin (ablative) for patients with non-usable hearing who have failed non-ablative approaches 3

For Intractable Vestibular Migraine

• Initiate preventive medications when symptoms occur ≥2 days per month: beta blockers (atenolol, propranolol), topiramate, or candesartan as first-line 5
• Assess efficacy after 2-3 months at therapeutic dose before declaring treatment failure 5
• Escalate to CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) as third-line preventive therapy, assessing efficacy after 3-6 months 5
• Consider onabotulinumtoxinA for chronic migraine with vestibular symptoms, assessing efficacy after 6-9 months 5

Vestibular Rehabilitation Therapy

VRT should be implemented for intractable vertigo regardless of etiology, as it promotes central compensation:

• Prescribe progressive exercises focusing on habituation, adaptation, and compensation for vestibular deficits 2
• Implement Cawthorne-Cooksey exercises (eye, head, and body movements in increasing difficulty) performed until symptoms fatigue 2
• Home-based therapy is equally effective as clinician-supervised therapy, though initial instruction is important 2
• VRT is particularly beneficial for elderly patients, potentially decreasing symptom recurrence 2

Pharmacological Management

Acute Symptom Control (Short-Term Only)

• Vestibular suppressants (meclizine, anticholinergics, benzodiazepines) are indicated for acute attacks but not for long-term management 5, 8, 6
• Avoid routine use of vestibular suppressants in BPPV, as they are not recommended and may impair central compensation 1
• Antiemetics (diphenhydramine, meclizine) can ameliorate symptoms during acute attacks 5

Medications to Avoid

• Do not prescribe oral ergot alkaloids, opioids, or barbiturates due to questionable efficacy with considerable adverse effects and dependency risk 5
• Avoid prolonged benzodiazepine use due to risk of drug dependence 5, 6

Identifying Comorbidities and Risk Factors

Intractable vertigo often reflects unrecognized comorbidities rather than true treatment resistance:

• Screen for vestibular migraine, which can mimic BPPV and other peripheral causes but requires different management 1, 5
• Assess for anxiety, depression, and sleep disturbances, which worsen vertigo and require concurrent treatment 5
• Check vitamin D levels, as low serum levels are a risk factor for BPPV recurrence 4
• Evaluate for persistent postural perceptual dizziness (PPPD), which commonly coexists with BPPV and requires specific management 4

Critical Pitfalls to Avoid

• Do not abandon treatment prematurely: efficacy of preventive medications takes weeks to months to establish 5
• Avoid overuse of acute medications, which risks medication overuse headache 5
• Do not assume treatment failure predicts failure of other drug classes: failure of one preventive treatment does not predict failure of others 5
• Avoid imaging in typical BPPV: radiographic imaging and vestibular testing are not indicated unless diagnosis is uncertain or additional symptoms suggest central pathology 1

Surgical Ablative Therapy

Reserve surgical ablation exclusively for patients who have failed all conservative measures and have non-usable hearing 3:

• Surgical canal plugging for intractable BPPV 4
• Labyrinthectomy or vestibular nerve section for intractable Ménière's disease 3