What are the recommended management options for vertigo?

Management of Vertigo

First-Line Treatment for BPPV (Most Common Cause)

Particle repositioning maneuvers, specifically the Epley maneuver, are the definitive treatment for benign paroxysmal positional vertigo (BPPV) with 90-98% success rates, and vestibular suppressant medications should NOT be routinely used. 1, 2, 3

Diagnostic Confirmation Required Before Treatment

• Diagnose posterior semicircular canal BPPV when vertigo with characteristic nystagmus is provoked by the Dix-Hallpike maneuver 1, 3
• If the Dix-Hallpike test is negative but history suggests BPPV, perform a supine roll test to assess for lateral semicircular canal BPPV 1
• Do NOT obtain radiographic imaging or vestibular testing unless the diagnosis is uncertain or additional neurological symptoms are present (abnormal cranial nerve findings, visual disturbances, severe headache) 1

Specific Treatment Protocols by Canal Involvement

For Posterior Canal BPPV (most common):

• Perform the Epley maneuver (Canalith Repositioning Procedure) with the following sequence: 3
  1. Patient seated with head turned 45° toward affected ear
  2. Rapidly move to supine with head hanging 20° below horizontal
  3. Turn head 90° to unaffected side
  4. Turn head and body another 90° (face down)
  5. Return to sitting position
• Success rate: 90-98% when performed correctly 3, 4
• No postprocedural restrictions are necessary 3

For Lateral Canal BPPV:

• Use the Gufoni maneuver or barbecue roll maneuver with 86-100% success rates 3, 4

Medication Guidelines: When NOT to Use Vestibular Suppressants

Do NOT routinely prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV treatment. 1, 2, 3

Limited Indications for Meclizine

• Consider meclizine ONLY for severe nausea/vomiting during the maneuver itself or in patients who refuse repositioning 2
• Maximum duration: 3-5 days 2
• FDA-approved dosage: 25-100 mg daily in divided doses 5
• Contraindications: Avoid in patients with asthma, glaucoma, or prostate enlargement 2, 5
• Significant risks in elderly: drowsiness, cognitive deficits, anticholinergic effects, increased fall risk 2, 5

Management of Specific Non-BPPV Vertigo Conditions

Ménière's Disease

• First-line preventive therapy: Dietary sodium restriction (1500-2300 mg daily) combined with diuretics 2
• Acute attacks: Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) 2
• Limit alcohol and caffeine intake 2
• Consider betahistine to increase inner ear vasodilation 2

Vestibular Neuritis/Labyrinthitis

• Initial stabilizing measures with vestibular suppressant medication for acute phase 6
• Follow with vestibular rehabilitation exercises 6

Vestibular Rehabilitation Therapy

Offer vestibular rehabilitation (VR) for persistent dizziness, chronic imbalance, or incomplete recovery—can be self-administered or therapist-directed. 1, 2, 4

• Indicated for persistent dizziness from any vestibular cause 2, 4
• Cawthorne-Cooksey exercises: progressive eye, head, and body movements performed until symptoms fatigue 4
• Brandt-Daroff exercises for BPPV: significantly less effective than repositioning maneuvers (25% vs 80.5% resolution) but may be used as adjunct 3, 4
• Home-based therapy equally effective as clinician-supervised therapy 4

Critical Follow-Up and Reassessment

Reassess all patients within 1 month after initial treatment to confirm symptom resolution. 1, 2, 3

Evaluation of Treatment Failures

• Reevaluate for persistent BPPV, coexisting vestibular conditions, or CNS disorders 1, 3, 4
• Check for canal conversion (occurs in ~6% of cases) requiring repositioning for newly affected canal 3, 4
• Consider surgical canal plugging for cases refractory to multiple repositioning attempts (>96% success rate) 3

Distinguishing Central from Peripheral Causes

Red flags suggesting central (CNS) causes requiring immediate evaluation: 1

• Downbeating nystagmus on Dix-Hallpike without torsional component
• Direction-changing nystagmus without head position changes
• Gaze-holding nystagmus
• Baseline nystagmus without provocative maneuvers
• Failure to respond to conservative management

High-Risk Central Causes to Exclude

• Vestibular migraine: ≥5 episodes lasting 5 minutes to 72 hours with migraine features 1
• Brainstem/cerebellar stroke: sudden onset with dysarthria, dysmetria, dysphagia, or sensory/motor loss 1
• Multiple sclerosis, intracranial tumors 1

Assessment of Modifying Factors

Question patients for factors requiring modified management: 1

• Impaired mobility or balance
• CNS disorders (including multiple sclerosis, traumatic brain injury)
• Lack of home support
• Increased fall risk
• Posttraumatic BPPV (requires repeated treatments in up to 67% of cases vs 14% for non-traumatic) 1

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers for BPPV 3
• Failing to reassess patients after initial treatment 3
• Missing canal conversions or multiple canal involvement 3
• Using vestibular suppressants as primary BPPV treatment (30.8% efficacy vs 78.6-93.3% for repositioning) 2