What is the management and treatment for vertigo and pulsatile tinnitus?

Management of Vertigo and Pulsatile Tinnitus

These are two distinct conditions requiring separate diagnostic and therapeutic approaches—vertigo management depends on the underlying cause (BPPV, Ménière's disease, or vestibular neuritis), while pulsatile tinnitus mandates imaging to exclude life-threatening vascular pathology.

Pulsatile Tinnitus: Imaging is Mandatory

Obtain imaging studies immediately for pulsatile tinnitus, as this symptom can indicate life-threatening vascular disorders including arteriovenous fistulas, carotid dissection, or intracranial hypertension. 1

Initial Diagnostic Approach for Pulsatile Tinnitus

• Perform otoscopic examination first—the cause may be visible as a retrotympanic vascular mass (glomus tumor) 1
• Obtain comprehensive audiologic examination to assess for asymmetric hearing loss 1
• Perform fundoscopic examination to exclude increased intracranial pressure 2
• Auscultate the neck, periauricular region, and skull for bruits 3

Imaging Algorithm for Pulsatile Tinnitus

If no retrotympanic mass is visible on otoscopy, proceed with CT angiography (CTA) of the head and neck as the first-line imaging study. 1

• CTA provides evaluation of both arterial anatomy (dissection, fibromuscular dysplasia, atherosclerosis) and venous structures (sigmoid sinus diverticulum, transverse sinus stenosis) in a single study 1
• Temporal bone CT reconstructions can be created from CTA source images without additional radiation exposure to assess for bony dehiscence (sigmoid plate, jugular bulb, superior semicircular canal) 1
• Contrast bolus timing can be adapted to define both arterial and venous phases 1

If CTA is negative or equivocal, obtain MRI/MRA with internal auditory canal protocol including thin-section heavily T2-weighted sequences and postcontrast volumetric T1-weighted images. 1

• Time-resolved gadolinium-enhanced MRA has high sensitivity and specificity for dural arteriovenous fistulas 1
• Venous arterial spin-labeling technique increases confidence in diagnosing dAVF on MRI 1

Catheter angiography is required if noninvasive imaging is negative but clinical suspicion remains high, or to clarify abnormal findings and guide endovascular treatment. 4, 2

Common Vascular Causes Requiring Urgent Intervention

• Dural arteriovenous fistulas (most common treatable vascular cause) 4, 5
• Carotid-cavernous sinus fistulas 4
• Internal carotid artery dissection 4
• Sigmoid sinus wall abnormalities (diverticulum or dehiscence) associated with intracranial hypertension 1
• Glomus tumors (visible on otoscopy if extending to middle ear) 3, 4

Critical Pitfall

Do NOT dismiss pulsatile tinnitus as benign—vascular disorders were found in 42% of patients in one series, with pulsatile tinnitus being the presenting symptom in 26 patients with vascular abnormalities. 4 Life-threatening causes such as arteriovenous shunts or carotid stenosis must be excluded. 3

Vertigo: Diagnosis Determines Treatment

Benign Paroxysmal Positional Vertigo (BPPV)

Perform canalith repositioning maneuvers (Epley or Semont) as first-line treatment for BPPV—success rates reach 80% with 1-3 treatments and 90-98% with additional maneuvers if needed. 1, 6

• Diagnose with Dix-Hallpike test for posterior canal BPPV or supine roll test for lateral canal BPPV 1
• BPPV is characterized by brief (seconds to minutes) episodes of intense vertigo triggered by specific head position changes (rolling over in bed, looking up, bending forward) 6, 7

Do NOT use meclizine or other vestibular suppressants as primary treatment for BPPV—they do not address the underlying cause and may interfere with recovery. 6, 8

• Canalith repositioning maneuvers have substantially higher treatment response (78.6%-93.3%) compared to medication alone (30.8%) 6
• Vestibular suppressants can be considered only for prophylaxis in patients who previously experienced severe nausea during repositioning maneuvers 6
• Observation alone is appropriate for some patients, as BPPV often resolves spontaneously 6

If symptoms persist after initial treatment, repeat the Dix-Hallpike or supine roll test and perform additional repositioning maneuvers. 1

Ménière's Disease

For acute Ménière's attacks, use vestibular suppressants for short-term symptomatic relief only (3-5 days maximum), combined with dietary sodium restriction (1500-2300 mg daily) for long-term management. 6, 7

• Ménière's disease presents with episodes lasting 20 minutes to 12 hours, accompanied by fluctuating hearing loss, tinnitus, and aural fullness 7
• Diuretics may be used to prevent flare-ups 6
• Intratympanic therapies may be considered for refractory cases 7

Acute Vestibular Syndrome (Vestibular Neuritis)

Use meclizine 25-100 mg daily in divided doses on an as-needed basis rather than scheduled dosing, limited to 3-5 days maximum during acute symptoms. 6, 7

• For severe nausea/vomiting, use prochlorperazine 5-10 mg orally or intravenously, maximum three doses per 24 hours 7
• For severe vertigo with anxiety component, consider short-term benzodiazepines (diazepam 10 mg), though they carry significant fall risk especially in elderly patients 7

Transition to vestibular rehabilitation therapy within 3-7 days as soon as acute symptoms are manageable—VRT is more effective than prolonged medication use for achieving lasting symptom resolution. 7

Critical Warnings About Vestibular Suppressants

Prolonged use of vestibular suppressants (>3-5 days) interferes with central vestibular compensation and delays natural recovery mechanisms. 6, 7, 8

• Vestibular suppressants are an independent risk factor for falls, particularly in elderly patients 6, 7, 8
• These medications cause drowsiness, cognitive deficits, and anticholinergic side effects (dry mouth, blurred vision, urinary retention) that are especially problematic in elderly patients 6
• Meclizine is not recommended as primary treatment for elderly patients with dizziness due to significant fall risk and lack of efficacy for common vestibular disorders 6

If meclizine worsens vertigo symptoms, discontinue it immediately—this suggests the medication is interfering with vestibular compensation or masking an underlying condition requiring different treatment. 8

Follow-Up Protocol

Reassess all patients within 1 month after initial treatment to document symptom resolution or persistence. 6, 7

• If vertigo symptoms persist beyond 4-6 weeks despite appropriate treatment, reconsider the diagnosis and evaluate for alternative causes (BPPV, Ménière's disease, vestibular migraine) 7
• For BPPV treatment failures, repeat the diagnostic positional test and perform additional canalith repositioning maneuvers 1
• Discontinue vestibular suppressants as soon as possible and transition to vestibular rehabilitation 6, 7

Lifestyle Modifications for All Vertigo Types

• Limit sodium intake to 1500-2300 mg daily to reduce inner ear fluid retention 6, 7
• Avoid excessive caffeine, alcohol, and nicotine, which can exacerbate vestibular symptoms 6, 7
• Maintain adequate hydration and regular sleep patterns 7
• Implement stress management techniques, as stress can worsen vertigo symptoms 7