What are the treatment options for vertigo?

Treatment of Vertigo

The treatment of vertigo depends critically on the underlying cause: for BPPV (the most common cause), perform the Epley maneuver immediately—do not prescribe medications; for Ménière's disease, use salt restriction plus diuretics for prevention and short-term vestibular suppressants only during acute attacks; for vestibular neuritis, use brief vestibular suppressants followed by rehabilitation therapy. 1, 2, 3

BPPV Treatment (First-Line for Most Cases)

Perform the Canalith Repositioning Procedure (Epley maneuver) as definitive treatment, achieving 90-98% success rates. 1, 2 This physical maneuver addresses the underlying pathophysiology by repositioning displaced otoconia, unlike medications which only mask symptoms. 3

• For posterior canal BPPV: Use the Epley maneuver with 80-93% success after 1-3 treatments 3
• For lateral canal BPPV: Use the Gufoni maneuver or barbecue roll maneuver with 86-100% success rates 1, 2
• Do NOT routinely prescribe vestibular suppressant medications for BPPV—they show only 30.8% efficacy compared to 78.6-93.3% for repositioning maneuvers 1, 3
• Meclizine may only be considered for severe nausea/vomiting during the maneuver itself, used for maximum 3-5 days 3

Reassessment Protocol

• Reassess within 1 month after initial treatment to confirm symptom resolution 1, 2, 3
• For persistent symptoms after 2-3 attempted maneuvers, evaluate for canal conversion (occurs in ~6% of cases) or CNS pathology 4, 2
• Consider MRI of brain and posterior fossa if symptoms are atypical or refractory to treatment 4

Ménière's Disease Treatment

Initiate dietary sodium restriction (1500-2300 mg daily) combined with diuretics as first-line preventive therapy. 3

Maintenance Therapy

• Offer diuretics and/or betahistine to reduce symptom frequency and prevent attacks 4
• Limit alcohol and caffeine intake 3
• Betahistine increases inner ear vasodilation 3

Acute Attack Management

• Use short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) only during acute vertigo attacks 3, 5
• Do NOT prescribe positive pressure therapy (Meniett devices)—systematic reviews show ineffectiveness 4

Refractory Cases

• Consider intratympanic steroid therapy for active disease not responsive to noninvasive treatment 4
• This option shows high-quality evidence (Grade B) with improved vertigo control and quality of life 4

Vestibular Neuritis/Labyrinthitis Treatment

• Use vestibular suppressants briefly at onset for symptom stabilization 6, 7
• Transition quickly to vestibular rehabilitation therapy—prolonged suppressant use delays central compensation 6
• Do NOT use vestibular rehabilitation during acute vertigo attacks in Ménière's disease 4

Vestibular Rehabilitation Therapy

Implement VRT for persistent dizziness from any vestibular cause, chronic imbalance, or incomplete recovery. 1, 3

• Use Cawthorne-Cooksey exercises: progressive eye, head, and body movements performed until symptoms fatigue 2
• For BPPV specifically, Brandt-Daroff exercises can promote debris dispersion 2
• Home-based therapy is equally effective as clinician-supervised therapy 2
• VRT is particularly beneficial for elderly patients, potentially decreasing symptom recurrence 2

Medication Guidelines and Critical Warnings

Vestibular suppressants should be used with extreme caution and only for short-term symptomatic relief in specific non-BPPV conditions. 3

Meclizine (FDA-Approved for Vestibular Vertigo)

• Indicated for vertigo associated with vestibular system diseases in adults 5
• Dosage: 25-100 mg daily in divided doses 5
• Contraindicated in patients with hypersensitivity to meclizine 5

Critical Adverse Effects and Contraindications

• Use with extreme caution in elderly patients: causes drowsiness, cognitive deficits, anticholinergic effects, and increased fall risk 3
• Avoid in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic action 3, 5
• Causes driving impairment and potential drug interactions 3
• Coadministration with other CNS depressants (including alcohol) results in increased CNS depression 5
• CYP2D6 inhibitors may increase meclizine levels due to metabolic interactions 5

Common Pitfalls to Avoid

• Never prescribe vestibular suppressants as primary treatment for BPPV—this delays definitive cure and exposes patients to unnecessary medication risks 1, 3
• Never continue vestibular suppressants long-term—they impair central compensation and vestibular rehabilitation effectiveness 6
• Never skip the 1-month reassessment—treatment failures require evaluation for alternative diagnoses including CNS disorders 4, 1, 3
• Never assume all vertigo is benign—CNS disorders can masquerade as BPPV in 3% of treatment failures 4

Patient Counseling Requirements

• Counsel regarding BPPV recurrence risk: 15% per year, reaching 37-50% at 5 years 4
• Discuss fall risk and safety implications 4, 3
• Educate on symptom recognition for earlier treatment of recurrences 4
• Warn about medication side effects, particularly drowsiness and fall risk with vestibular suppressants 3, 5