What are the current management options for vertigo?

Management of Vertigo

First-Line Treatment: Identify the Type of Vertigo

The management of vertigo depends critically on distinguishing between benign paroxysmal positional vertigo (BPPV) and other causes, as BPPV requires physical repositioning maneuvers rather than medications, while other peripheral vestibular disorders may benefit from short-term vestibular suppressants. 1

For BPPV (Most Common Cause)

Particle repositioning maneuvers are the definitive treatment for BPPV, NOT medications. 1

• Posterior canal BPPV: Perform the Epley maneuver (canalith repositioning procedure), which achieves 78.6-93.3% symptom resolution compared to only 30.8% with medication alone 2, 3
• Lateral canal BPPV: Use the Gufoni maneuver or barbecue roll maneuver, with 86-100% success rates 3
• Do NOT routinely prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV, as they do not address the underlying cause and may delay recovery 1
• Observation is an acceptable alternative, as spontaneous resolution occurs in 20-80% of cases within 1 month, though repositioning maneuvers offer faster relief (up to 4.1 times greater resolution rates) 1

Common pitfall: Emergency departments frequently mismanage BPPV by ordering brain imaging and prescribing meclizine, neither of which is recommended by guidelines 4

For Non-BPPV Peripheral Vertigo (Vestibular Neuritis, Ménière's Disease)

Vestibular suppressants should only be used for SHORT-TERM management of severe acute symptoms, not as definitive treatment. 5

Medication Options (Use Sparingly and Briefly)

• Meclizine: 25-100 mg daily in divided doses, used PRN rather than scheduled to avoid interfering with vestibular compensation 5, 2, 6
• Benzodiazepines (e.g., diazepam 10 mg): For short-term management of severe vertigo and associated anxiety 5
• Prochlorperazine: 5-10 mg orally or IV (maximum 3 doses per 24 hours) for severe nausea/vomiting only, not as primary vertigo treatment 5, 2

Critical Warnings About Vestibular Suppressants

• Significantly increase fall risk, especially in elderly patients 5, 2
• Cause drowsiness, cognitive deficits, and anticholinergic side effects (dry mouth, blurred vision, urinary retention) 5, 6
• Interfere with central vestibular compensation when used long-term 1, 5
• Should be avoided in patients with asthma, glaucoma, or prostate enlargement 6

For Ménière's Disease Specifically

• Acute attacks: Limited course of vestibular suppressants (meclizine or benzodiazepines) during attacks only 5, 2
• Long-term prevention: Salt restriction (low-sodium diet) and diuretics are the mainstay, NOT continuous vestibular suppressants 5, 7, 8
• Betahistine showed no significant benefit over placebo in reducing attack frequency 5

Vestibular Rehabilitation Therapy

Vestibular rehabilitation should be offered as an alternative or adjunct to repositioning maneuvers for BPPV, and is particularly important for non-BPPV vestibular disorders. 1

• Cawthorne-Cooksey exercises: Progressive eye, head, and body movements to promote habituation and compensation 3
• Brandt-Daroff exercises: Specific for BPPV, involving rapid lateral head/trunk tilts 3
• Home-based therapy is equally effective as clinician-supervised therapy 3
• No serious adverse events reported in clinical trials 3

Lifestyle Modifications

• Limit salt/sodium intake (especially critical for Ménière's disease) 5, 2
• Avoid excessive caffeine, alcohol, and nicotine 5, 2
• Maintain adequate hydration, regular exercise, and sufficient sleep 5, 2
• Manage stress appropriately 5, 2

Follow-Up and Reassessment

Reassess ALL patients within 1 month after initial treatment to confirm symptom resolution or identify treatment failures. 1

• Complete symptom resolution is the expected outcome for successful BPPV treatment 1
• Persistent symptoms warrant reevaluation for:
  • Incorrect initial diagnosis (1.1-3% of "BPPV" cases are actually CNS lesions) 1
  • Involvement of different semicircular canals (canal conversion occurs in ~6% of cases) 3
  • Underlying peripheral vestibular or CNS disorders 1
• Transition from medications to vestibular rehabilitation when appropriate to promote long-term recovery 5, 2

Special Populations and Modifying Factors

Assess for factors that modify management: 1

• Impaired mobility or balance (increased fall risk) 1
• CNS disorders (multiple sclerosis, traumatic brain injury—posttraumatic BPPV requires repeated treatments in 67% of cases vs. 14% for non-traumatic) 1
• Lack of home support 1
• Elderly patients (higher fall risk, avoid vestibular suppressants when possible) 2

What NOT to Do

• Do NOT order routine radiographic imaging or vestibular testing for straightforward BPPV unless diagnosis is uncertain or additional neurological symptoms are present 1
• Do NOT prescribe meclizine as primary treatment for BPPV—it is explicitly contraindicated by guidelines 2
• Do NOT use vestibular suppressants long-term for any vestibular disorder 1, 5