What is the treatment for vertigo?

Treatment of Vertigo

For benign paroxysmal positional vertigo (BPPV)—the most common cause of vertigo—perform the Epley maneuver (canalith repositioning procedure) as first-line treatment, achieving 80-98% success rates, and do NOT use vestibular suppressant medications as primary therapy. 1, 2, 3

Initial Diagnostic Classification

Before treating vertigo, distinguish between peripheral and central causes, as this fundamentally changes management:

• Peripheral vertigo (BPPV, vestibular neuronitis, Ménière's disease) responds to repositioning maneuvers and vestibular rehabilitation 2, 3
• Central vertigo (stroke, cerebellar pathology, mass lesions) requires urgent neuroimaging and etiology-specific treatment rather than symptomatic management 4

Red flags for central vertigo requiring immediate MRI include: downbeating nystagmus on Dix-Hallpike, direction-changing nystagmus without head position changes, gaze-evoked nystagmus, dysarthria, dysmetria, dysphagia, sensory/motor deficits, Horner's syndrome, or profound gait dysfunction 4

Treatment Algorithm by Etiology

BPPV (Most Common Cause)

Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV, then immediately treat with the Epley maneuver (canalith repositioning procedure). 1, 2, 3

• The Epley maneuver achieves 90-98% success rates when performed correctly 3
• Repeat the maneuver 1-3 times if initial treatment fails 2
• For lateral canal BPPV (diagnosed with supine roll test), use the Gufoni maneuver or barbecue roll maneuver with 86-100% success rates 3

Do NOT prescribe vestibular suppressants (meclizine) as primary treatment for BPPV—they show only 30.8% efficacy compared to 78.6-93.3% for repositioning maneuvers and do not address the underlying pathophysiology 2, 3

• Meclizine may only be considered for severe nausea/vomiting during the maneuver itself or in patients who refuse repositioning 2
• Maximum duration: 3-5 days if used 2
• FDA-approved dosing: 25-100 mg daily in divided doses 5

Acute Vestibular Neuronitis/Labyrinthitis

Treat with short-term vestibular suppressants (meclizine 25-100 mg daily) for 3-5 days maximum, followed by vestibular rehabilitation exercises. 2, 6

• Vestibular suppressants are appropriate here because this represents acute unilateral vestibular failure, not BPPV 6
• Critical caveat: Prolonged use beyond 3-5 days interferes with central compensation mechanisms and prolongs recovery 4, 7
• Begin vestibular rehabilitation exercises as soon as acute symptoms subside to promote compensation 2, 3

Ménière's Disease

Implement dietary sodium restriction (1500-2300 mg daily) combined with diuretics as first-line preventive therapy. 2

• Limit alcohol and caffeine intake 2
• For acute vertigo attacks: short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) 2
• Consider betahistine to increase inner ear vasodilation 2

Vestibular Migraine

Treat according to migraine management principles with prophylactic medications (tricyclic antidepressants, beta blockers, or calcium channel blockers) and acute abortive therapy. 3, 6

• Diagnostic criteria must include ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, migraine history, and ≥1 migraine symptom during ≥50% of dizzy episodes 4
• Dietary modifications are also recommended 6

Central Vertigo

Activate acute stroke protocols immediately—do NOT treat with vestibular suppressants, as they mask symptoms without addressing life-threatening CNS pathology. 4

• Obtain urgent MRI with diffusion-weighted imaging (DWI) for suspected brainstem or cerebellar stroke 4
• Thrombolysis or thrombectomy within appropriate time windows for ischemic stroke 4
• Neurosurgical consultation for hemorrhagic stroke or cerebellar infarction with mass effect 4
• Critical warning: 10% of cerebellar strokes present similarly to peripheral vestibular processes—early recognition prevents herniation 4

Medication Safety Considerations

Use vestibular suppressants with extreme caution, particularly in elderly patients, due to significant adverse effects:

• Drowsiness, cognitive deficits, anticholinergic effects, and increased fall risk 2, 3
• Contraindications: asthma, glaucoma, prostate enlargement 2, 5
• Potential for drug interactions with other CNS depressants including alcohol 5
• Driving impairment warning required 5
• As meclizine is metabolized by CYP2D6, potential drug-drug interactions exist with CYP2D6 inhibitors 5

Vestibular Rehabilitation

Prescribe vestibular rehabilitation for persistent dizziness from any vestibular cause, chronic imbalance, or incomplete recovery. 2, 3

• Can be self-administered or therapist-directed 2
• Indicated after acute phase of vestibular neuronitis resolves 6
• Should NOT be delayed by prolonged vestibular suppressant use 4, 7

Follow-Up and Treatment Failure Management

Reassess all patients within 1 month after initial treatment to document symptom resolution or persistence. 2, 3, 4

For persistent symptoms after initial therapy:

• Repeat Dix-Hallpike test to confirm persistent BPPV and perform additional repositioning maneuvers 1
• Evaluate for canal conversion (involvement of different semicircular canals) 1
• Consider coexisting vestibular conditions 1
• After 2-3 failed repositioning attempts or with atypical features: obtain thorough neurological examination and MRI of brain and posterior fossa to exclude CNS disorders masquerading as BPPV 1, 4

Counsel patients on BPPV recurrence risk:

• 15% per year overall recurrence rate 1
• 37-50% recurrence at 5 years 1
• Higher recurrence rates after trauma 1
• Educate on fall risk and importance of early return for retreatment if symptoms recur 1

Common Pitfalls to Avoid

• Never use vestibular suppressants as primary treatment for BPPV—this represents the single most important treatment error, as it provides inferior outcomes (30.8% vs 90-98% success) and delays definitive cure 2, 3
• Never prescribe vestibular suppressants long-term—they interfere with central compensation and prolong symptoms 4, 7
• Never assume peripheral vertigo without checking for central red flags—3% of presumed BPPV treatment failures have underlying CNS disorders 1
• Never treat vertigo with medications alone without performing diagnostic maneuvers—you will miss easily curable BPPV 1, 3