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

The treatment of vertigo depends entirely on identifying the underlying cause, as vertigo is a symptom, not a disease. 3

For BPPV (Most Common Cause)

First, confirm the diagnosis and canal involved:

• Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV (most common subtype) 1, 2
• Perform the supine roll test to diagnose lateral canal BPPV 1, 2

Treatment based on canal involvement:

Posterior Canal BPPV:

• Perform the Epley maneuver immediately as first-line treatment with the following sequence: 1, 2
  1. Patient seated with head turned 45° toward affected ear 2
  2. Rapidly move to supine with head hanging 20° below horizontal 2
  3. Turn head 90° to unaffected side 2
  4. Turn head and body another 90° (face down) 2
  5. Return to sitting 2
• Success rate: 90-98% when performed correctly 1, 2
• Post-procedural restrictions are NOT necessary 2

Lateral Canal BPPV:

• Use the Gufoni maneuver or barbecue roll maneuver 1, 2
• Success rate: 86-100% 1, 2

Critical Management Points:

• Do NOT prescribe vestibular suppressants (antihistamines, benzodiazepines) as primary treatment 4, 2, 5
• Meclizine may only be considered for short-term management of severe nausea/vomiting, NOT for treating the vertigo itself 2, 5, 6
• Reassess within 1 month to confirm symptom resolution 1, 2, 5

For Treatment Failures or Persistent Symptoms

If symptoms persist after initial Epley maneuver:

• Re-evaluate for canal conversion (occurs in ~6% of cases) and treat the newly affected canal 1, 2, 5
• Assess for multiple canal involvement 1
• Consider coexisting vestibular conditions or central nervous system disorders 2, 5
• For refractory cases after multiple repositioning attempts, surgical canal plugging has >96% success rates 2

Alternative Treatment: Vestibular Rehabilitation Therapy (VRT)

When to consider VRT:

• For persistent dizziness from vestibular causes after repositioning maneuvers 5
• As an adjunctive or alternative option for BPPV, though initially less effective than repositioning maneuvers 1
• Particularly beneficial for elderly patients to decrease recurrence rates 1

VRT Protocol:

• Implement Cawthorne-Cooksey exercises (eye, head, and body movements in increasing difficulty) performed until symptoms fatigue 1
• For BPPV specifically, Brandt-Daroff exercises involve rapid lateral head/trunk tilts, though these are significantly less effective than Epley maneuver (25% vs 80.5% resolution at 7 days) 2
• Home-based therapy is equally effective as clinician-supervised therapy 1
• VRT is safe with no serious adverse events reported 1

For Other Causes of Vertigo

Ménière's Disease:

• Salt restriction and diuretics for long-term management 5
• Short-term vestibular suppressants only during acute attacks 5
• Treatment goals: reduce severity/frequency of attacks, relieve symptoms, improve quality of life 1
• Non-ablative procedures preferred for patients with usable hearing 1

Acute Vestibular Neuronitis/Labyrinthitis:

• Initial stabilizing measures with vestibular suppressant medication 3
• Follow with vestibular rehabilitation exercises 3

Vertiginous Migraine:

• Dietary changes, tricyclic antidepressant, and beta blocker or calcium channel blocker 3

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers for BPPV 2
• Failing to reassess patients after initial treatment 2
• Missing canal conversions or multiple canal involvement 2
• Using vestibular suppressants in elderly patients without considering increased fall risk, drowsiness, and cognitive deficits 5

Why Vestibular Suppressants Should Be Avoided in BPPV

The evidence strongly recommends against routine use of vestibular suppressants (benzodiazepines like diazepam/clonazepam, antihistamines like meclizine/diphenhydramine) because: 4

• They do not address the underlying mechanical cause of BPPV 5
• They interfere with central compensation in peripheral vestibular conditions 4
• They only reduce subjective spinning sensation without resolving the condition 4
• Observation alone (mean 39 days to spontaneous resolution) is preferable to medication use 4

The FDA-approved indication for meclizine is for vertigo associated with vestibular system diseases, but guideline evidence clearly shows it should not be routinely used for BPPV. 6