What are the management options for vertigo?

Management of Vertigo

Particle repositioning maneuvers (Epley maneuver) are the definitive first-line treatment for BPPV with 80-93% success rates, while vestibular suppressant medications should NOT be routinely used for BPPV and are reserved only for short-term symptomatic relief in specific non-BPPV vestibular conditions. 1, 2

Diagnostic Approach: Identify the Pattern

The management algorithm depends entirely on distinguishing between three clinical presentations:

1. Brief Episodic Vertigo (Triggered by Head Movement)

Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV, which produces torsional upbeating nystagmus with vertigo. 1 If negative, perform a supine roll test for lateral canal BPPV. 1

• If typical BPPV is confirmed: Proceed directly to particle repositioning maneuver—do NOT order imaging or vestibular testing unless atypical features are present. 1, 2
• Red flags requiring imaging: Downbeating nystagmus without torsional component, direction-changing nystagmus without head position changes, baseline nystagmus without provocative maneuvers, or lack of response to repositioning maneuvers. 1, 3

2. Prolonged Spontaneous Vertigo (Acute Vestibular Syndrome)

Rule out posterior circulation stroke first—this is the most dangerous pitfall, as 10% of cerebellar strokes mimic benign peripheral vertigo. 1

• Central warning signs: Dysarthria, dysmetria, dysphagia, sensory/motor loss, Horner's syndrome, or direction-switching nystagmus. 1
• If peripheral vestibular neuritis is confirmed: Use vestibular suppressants for only 3-5 days maximum, then transition to vestibular rehabilitation exercises. 2, 4

3. Recurrent Episodic Vertigo (Ménière's Disease)

First-line preventive therapy: Dietary sodium restriction (1500-2300 mg daily) combined with diuretics. 2

• Acute attacks: Meclizine 25-100 mg daily in divided doses for short-term relief only. 2, 5
• Additional measures: Limit alcohol and caffeine intake; consider betahistine for inner ear vasodilation. 2

Treatment Specifics

Particle Repositioning Maneuvers (BPPV)

The Epley maneuver achieves 4.1 times greater symptom resolution compared to controls (78.6-93.3% success vs 30.8% with medications). 1, 2

• Do NOT recommend postprocedural postural restrictions—this is a strong recommendation against this outdated practice. 1
• Reassess within 1 month to document resolution or persistence. 1, 2

Vestibular Suppressant Medications: When and When NOT to Use

Do NOT routinely treat BPPV with meclizine, antihistamines, or benzodiazepines—they have no evidence supporting efficacy in BPPV and may impair vestibular compensation. 1, 2

Limited acceptable uses for meclizine (25-100 mg daily): 2, 5

• Severe nausea/vomiting during the repositioning maneuver itself
• Patients who refuse repositioning maneuvers
• Acute Ménière's disease attacks
• Acute vestibular neuritis (maximum 3-5 days only)

Critical warnings for meclizine use: 2, 5

• Avoid in patients with asthma, glaucoma, or prostate enlargement
• Significant adverse effects in elderly: drowsiness, cognitive deficits, anticholinergic effects, increased fall risk
• Warn patients against driving or operating machinery
• Avoid concurrent alcohol use
• Drug interactions with CYP2D6 inhibitors

Vestibular Rehabilitation

Indicated for: 2

• Persistent dizziness from any vestibular cause
• Chronic imbalance
• Incomplete recovery after acute vestibular neuritis
• Treatment failure with repositioning maneuvers

Can be self-administered or therapist-directed. 2

Common Pitfalls to Avoid

1. Missing posterior circulation stroke: The single most dangerous error—always assess for central signs before assuming peripheral vertigo. 1

2. Prescribing meclizine as primary BPPV treatment: This contradicts strong guideline recommendations and delays definitive cure with repositioning maneuvers. 1, 2

3. Ordering unnecessary imaging for typical BPPV: Do not obtain imaging in patients meeting diagnostic criteria for BPPV unless additional inconsistent signs/symptoms are present. 1

4. Prolonged vestibular suppressant use: These medications interfere with the natural compensation process and should be limited to 3-5 days maximum. 2, 6

5. Assuming atypical Dix-Hallpike results are still BPPV: Negative or atypical testing increases risk of central pathology requiring imaging. 3, 1

Patient Education Requirements

Counsel all patients on: 1, 2

• Fall risk and safety precautions
• Potential for disease recurrence (especially BPPV)
• Importance of 1-month follow-up
• When to seek emergency care (new neurological symptoms)