From the Guidelines
For a 70-year-old male with vertigo, I strongly recommend starting with a thorough evaluation to determine if it's peripheral or central vertigo, and then performing the Epley maneuver to reposition displaced otoconia, as it has a high success rate of around 80% with only 1-3 treatments, as stated in the clinical practice guideline: benign paroxysmal positional vertigo (update) 1. The evaluation should include simple bedside testing, such as the Dix-Hallpike test or supine roll test, to confirm the diagnosis of Benign Paroxysmal Positional Vertigo (BPPV) 1. Key points to consider in the management of BPPV include:
- Differential diagnosis to rule out other causes of imbalance, dizziness, and vertigo 1
- Assessment of modifying factors, such as impaired mobility or balance, central nervous system disorders, and increased risk for falling 1
- Avoidance of radiographic imaging and vestibular testing unless additional signs or symptoms are present that warrant further evaluation 1
- Consideration of vestibular rehabilitation therapy for patients with persistent symptoms or underlying vestibular or central nervous system disorders 1
- Education of patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up 1 It is also important to note that vestibular suppressant medications, such as antihistamines and benzodiazepines, are not recommended for routine treatment of BPPV due to their potential for significant harm, including drowsiness, cognitive deficits, and increased risk of falls 1. Instead, lifestyle modifications, such as avoiding sudden head movements and staying hydrated, can help alleviate symptoms and improve quality of life. If symptoms persist or are accompanied by neurological symptoms, further evaluation, including MRI imaging, may be necessary to rule out central causes of vertigo.
From the FDA Drug Label
Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1).
For a 70 year old male with vertigo, meclizine (PO) can be considered as a treatment option, as it is indicated for the treatment of vertigo in adults 2.
From the Research
Diagnosis of Vertigo
- The diagnosis of vertigo in a 70-year-old male involves determining whether the patient has a peripheral or central cause of vertigo, as stated in the study by 3.
- A detailed history and physical examination, including special tests such as the Dix-Hallpike maneuver, are essential in making this distinction, as noted in the study by 3.
- Associated neurologic signs and symptoms, such as nystagmus that does not lessen when the patient focuses, point to central causes of vertigo, which require further work-up with selected laboratory and radiologic studies, as mentioned in the study by 3.
Treatment of Benign Paroxysmal Positional Vertigo (BPPV)
- The Epley maneuver is a safe and effective treatment for posterior canal BPPV, as evidenced by the studies by 4 and 5.
- The Epley maneuver has been shown to be more effective than a sham maneuver or control in resolving vertigo symptoms, with a significant increase in the proportion of patients resolving from 21% to 56%, as reported in the study by 4.
- The Epley maneuver is also more effective than vestibular rehabilitation at 1-week follow-up, with regard to patient-reported symptom relief and conversion of the Dix-Hallpike maneuver from positive to negative, as stated in the study by 6.
Considerations for Treatment
- The Epley maneuver is generally well-tolerated, with infrequent reports of adverse effects, such as nausea, and no serious adverse effects, as noted in the studies by 4 and 5.
- The number-needed-to-treat for the Epley maneuver is 3, indicating that it is a relatively effective treatment for BPPV, as reported in the study by 5.
- Further studies on the implementation and clinician education of the Epley maneuver in the emergency department are needed, as suggested in the study by 5.