What are the treatment options for vertigo?

Treatment of Vertigo

For benign paroxysmal positional vertigo (BPPV)—the most common cause of vertigo—perform the Epley maneuver immediately, which achieves 90-98% success rates and is far superior to medications. 1, 2

Diagnosis First: Identify the Type of Vertigo

The treatment approach depends entirely on the underlying cause, which can be determined through specific bedside testing:

For BPPV (Most Common)

• Diagnose posterior canal BPPV using the Dix-Hallpike maneuver: bring the patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus 3, 2
• Diagnose lateral canal BPPV using the supine roll test 1, 2
• BPPV presents as brief episodes (seconds to minutes) of spinning triggered by position changes like rolling over in bed, looking up, or bending over 3

For Ménière's Disease

• Characterized by episodic vertigo lasting 20 minutes to hours, accompanied by fluctuating hearing loss, tinnitus, and aural fullness 3
• Diagnosis is clinical based on this symptom complex 3

For Vestibular Neuronitis

• Presents as acute, continuous vertigo lasting hours to days with spontaneous nystagmus 4, 5
• No hearing loss (distinguishes from labyrinthitis) 4

Treatment Algorithm by Diagnosis

BPPV Treatment (First-Line)

Perform canalith repositioning maneuvers immediately—do not prescribe medications as primary treatment:

Posterior Canal BPPV (Most Common)

• Epley maneuver is the definitive treatment with 80-93% success after 1-3 treatments 1, 6, 2
• The sequence: patient seated with head turned 45° toward affected ear → rapidly move to supine with head hanging 20° below horizontal → turn head 90° to unaffected side → turn head and body another 90° (face down) → return to sitting 2
• Do not prescribe post-maneuver activity restrictions—they are unnecessary 2

Lateral Canal BPPV

• Use the Gufoni maneuver or barbecue roll maneuver with 86-100% success rates 1, 2

Critical Pitfall to Avoid

• Do not use vestibular suppressants (meclizine) as primary BPPV treatment—they have only 30.8% efficacy compared to 78.6-93.3% for repositioning maneuvers 6
• Meclizine may only be considered for severe nausea/vomiting during the maneuver itself, used for maximum 3-5 days 6

Follow-Up

• Reassess within 1 month to document resolution or persistence 3, 1, 2
• If symptoms persist, re-evaluate for canal conversion (occurs in ~6% of cases), involvement of other canals, or alternative diagnoses 1, 2

Ménière's Disease Treatment

Start with dietary sodium restriction (1500-2300 mg daily) combined with diuretics as first-line preventive therapy: 6

Acute Attack Management

• Meclizine 25-100 mg daily in divided doses for short-term symptomatic relief during acute vertigo attacks 6, 7
• Limit alcohol and caffeine intake 6

Maintenance Therapy

• Diuretics and/or betahistine may be offered to reduce attack frequency 3, 6
• Betahistine increases inner ear vasodilation 6

Escalation for Treatment Failures

• Intratympanic steroids for active disease not responsive to noninvasive treatment 3
• Intratympanic gentamicin for definitive vertigo control in refractory cases, though this carries risk of hearing loss 3
• Surgical options (labyrinthectomy, vestibular nerve section) reserved for patients without useful hearing 3

Important Contraindication

• Do not prescribe positive pressure therapy (Meniett device)—randomized trials show it is ineffective 3

Vestibular Neuronitis/Labyrinthitis Treatment

• Short-term vestibular suppressants (meclizine 25-100 mg daily) for initial stabilization during acute phase 6, 4
• Corticosteroids for acute vestibular neuritis 8
• Transition to vestibular rehabilitation after acute symptoms stabilize 6, 4

Vestibular Rehabilitation Therapy (VRT)

Use VRT for persistent dizziness, chronic imbalance, or incomplete recovery from any vestibular cause—not for acute vertigo attacks: 3, 6

When to Prescribe VRT

• Persistent symptoms after BPPV treatment 1, 6
• Chronic imbalance in Ménière's disease (but not during acute attacks) 3
• Incomplete compensation after vestibular neuronitis 6, 4

VRT Components

• Cawthorne-Cooksey exercises: progressive eye, head, and body movements performed until symptoms fatigue, forcing central nervous system compensation through habituation 1
• Brandt-Daroff exercises for BPPV: rapid lateral head/trunk tilts (though significantly less effective than Epley maneuver: 25% vs 80.5% resolution) 2
• Home-based therapy is equally effective as clinician-supervised therapy after initial instruction 1

Safety Profile

• VRT is safe with no serious adverse events reported in clinical trials 1
• May decrease recurrence rates, particularly beneficial for elderly patients 1

Medication Guidelines and Critical Warnings

Meclizine (Vestibular Suppressant)

Prescribe meclizine only for short-term symptomatic relief in non-BPPV conditions or severe nausea—never as primary BPPV treatment:

FDA-Approved Dosing

• 25 mg to 100 mg daily in divided doses for vertigo associated with vestibular system diseases 7
• Maximum duration: 3-5 days 6

Contraindications

• Hypersensitivity to meclizine 7
• Use with caution in asthma, glaucoma, or prostate enlargement due to anticholinergic effects 6, 7

Adverse Effects (Particularly in Elderly)

• Drowsiness and cognitive deficits 6
• Anticholinergic effects (dry mouth, blurred vision) 7
• Increased fall risk—critical concern in elderly patients with vertigo 6
• Impaired driving ability 6, 7

Drug Interactions

• Avoid coadministration with other CNS depressants including alcohol—results in increased CNS depression 7
• CYP2D6 inhibitors may increase meclizine levels 7

Common Clinical Pitfalls

• Prescribing meclizine instead of performing repositioning maneuvers for BPPV—this is the most common error 6, 2
• Failing to reassess patients within 1 month after initial treatment 3, 2
• Missing canal conversions or multiple canal involvement in persistent BPPV 1, 2
• Prescribing vestibular suppressants long-term—they delay central compensation 6
• Using vestibular rehabilitation during acute Ménière's attacks—it is contraindicated 3