What is the treatment for visual vertigo?

Treatment of Visual Vertigo

Visual vertigo should be treated with vestibular rehabilitation therapy incorporating graded exposure to dynamic visual environments, as this approach has demonstrated significant symptom improvement (59.2% reduction) compared to static visual training. 1

Understanding Visual Vertigo

Visual vertigo (VV) is a specific condition where symptoms are provoked or exacerbated by disorienting visual stimuli such as supermarkets, moving objects, or busy environments. 2 This differs from other vestibular disorders because patients demonstrate abnormally large perceptual and postural responses to visual environments, with increased visual dependence and difficulty resolving conflicts between visual and vestibulo-proprioceptive inputs. 2

The underlying pathophysiology typically involves a peripheral vestibular disorder (present in 81% of VV patients), which leads to compensatory over-reliance on visual input for balance. 2

Primary Treatment Approach

Vestibular Rehabilitation with Dynamic Visual Exposure

The cornerstone treatment is customized vestibular rehabilitation exercises combined with exposure to optokinetic stimuli and dynamic visual environments. 1, 2

Key components include:

• Head-eye movement exercises performed in progressively challenging visual contexts (starting with simple environments and advancing to complex, moving visual scenes). 3, 1

• Dynamic virtual reality or real-world exposure to visually provocative environments such as crowded spaces, moving patterns, or rotating stimuli, which produces significantly better outcomes than static visual training. 1

• Gaze stabilization exercises requiring head movement during visual fixation or visual target changes, performed multiple times daily. 3, 4

• Balance training with reduced support base while performing various upper-extremity tasks and exposing patients gradually to various sensory and motor environments. 3

Treatment Frequency and Duration

Exercises should be performed several times daily for at least 4 weeks, with twice-weekly supervised sessions combined with daily home exercises. 1 Even brief periods of exercise are sufficient if performed consistently throughout the day. 3

Medication Management

Vestibular suppressants (antihistamines, benzodiazepines) should be avoided or withdrawn as soon as possible, as they interfere with central vestibular compensation and can delay recovery. 5, 6

• If medications are necessary for severe acute symptoms, use them as needed rather than on a scheduled basis. 5

• These medications cause significant side effects including drowsiness, cognitive deficits, and increased fall risk, particularly in elderly patients. 6, 5

Treatment Algorithm

1. Confirm the diagnosis by identifying peripheral vestibular dysfunction (present in most VV cases) and documenting symptom provocation by specific visual contexts. 2

2. Discontinue or minimize vestibular suppressants to allow central compensation mechanisms to function. 5, 6

3. Initiate vestibular rehabilitation with emphasis on:

   • Gaze stabilization exercises 3
   • Progressive exposure to dynamic visual stimuli 1
   • Balance training in visually challenging contexts 3

4. Advance to dynamic visual environments (virtual reality, crowded spaces, moving visual patterns) as tolerance improves, as this produces 59.2% symptom improvement versus 1.6% with static training. 1

5. Continue exercises for minimum 4 weeks with reassessment at 1 month to document progress. 6, 1

Expected Outcomes

Patients with unilateral peripheral vestibular injury have the best prognosis for full recovery. 4 Those with bilateral lesions will show improvement but may have permanent deficits. 4 VV symptoms specifically improve significantly with dynamic visual exposure therapy, with anxiety scores also trending toward improvement. 1

Critical Pitfalls to Avoid

• Do not use vestibular rehabilitation during acute vertigo attacks, as this may worsen symptoms and is contraindicated. 7, 8

• Do not prescribe long-term vestibular suppressants, which impede central compensation and prolong recovery. 5, 6

• Do not use static visual training alone when dynamic visual exposure is available, as outcomes are dramatically inferior (1.6% vs 59.2% improvement). 1

• Do not mistake VV for simple BPPV or Ménière's disease, as treatment approaches differ significantly. 8, 6