What are the treatment options for vertigo?

Treatment of Vertigo

The treatment of vertigo depends critically on the underlying cause: for BPPV (the most common cause), particle repositioning maneuvers like the Epley maneuver are first-line therapy with 80-93% success rates, while vestibular suppressant medications should be avoided as primary treatment; for other peripheral causes like Ménière's disease or vestibular neuritis, short-term vestibular suppressants (meclizine 25-100 mg daily) may be used only for acute symptom relief, not as definitive therapy. 1, 2, 3

Diagnostic Framework: Identify the Cause First

Before treating vertigo, determine whether it is:

• BPPV (most common): Brief episodes (seconds to minutes) triggered by head position changes 1, 2
• Ménière's disease: Episodic vertigo with hearing loss, tinnitus, and aural fullness 1, 3
• Vestibular neuritis: Acute, prolonged vertigo (hours to days) without hearing loss 4, 5
• Central causes: Red flags include downbeating nystagmus, direction-changing nystagmus, or neurological signs requiring imaging 3

Treatment Algorithm by Diagnosis

For BPPV (First-Line: Physical Maneuvers, NOT Medications)

Particle repositioning maneuvers are the definitive treatment—medications are explicitly NOT recommended as primary therapy. 1, 2

• Perform the Epley maneuver (or Semont maneuver) as first-line treatment with 80-93% success after 1-3 treatments 2, 3
• Do NOT routinely prescribe meclizine or other vestibular suppressants for BPPV—they have only 30.8% improvement rates compared to 78.6-93.3% for repositioning maneuvers 2
• Vestibular suppressants can actually slow recovery and increase fall risk, especially in elderly patients 2, 3

Very limited exceptions for medication use in BPPV:

• Short-term meclizine (maximum 3-5 days) ONLY for severe nausea/vomiting during the maneuver itself 2, 3
• Prophylaxis before the maneuver in patients with history of severe nausea during prior attempts 2
• Patients who absolutely refuse repositioning maneuvers 2

Reassess within 1 month to confirm symptom resolution or evaluate for treatment failure 1, 3

For Ménière's Disease

Dietary modification and diuretics are first-line preventive therapy, with vestibular suppressants reserved only for acute attacks. 1, 3, 6

Preventive management:

• Sodium restriction to 1500-2300 mg daily 3, 6
• Diuretics for long-term prevention 3, 7
• Limit caffeine, alcohol, and nicotine 3, 6

Acute attack management:

• Meclizine 25-100 mg daily in divided doses for SHORT-TERM use during acute attacks only, not continuous therapy 3, 6, 8
• Consider prochlorperazine for severe nausea/vomiting (5-10 mg, maximum 3 doses per 24 hours) 6
• Betahistine showed no significant benefit over placebo in reducing attack frequency 6

For Vestibular Neuritis/Labyrinthitis

Brief vestibular suppressant use followed by early vestibular rehabilitation. 7, 4

• Meclizine 25-100 mg daily for SHORT-TERM symptom relief (3-5 days maximum) 3, 8
• Transition quickly to vestibular rehabilitation to promote central compensation 3, 7
• Prolonged vestibular suppressant use interferes with compensation 6, 7

For Non-Specific Peripheral Vertigo

• Meclizine should be used PRN (as-needed) rather than scheduled to avoid interfering with vestibular compensation 6
• Benzodiazepines may help with severe symptoms and psychological anxiety 6, 7
• Prochlorperazine for severe nausea/vomiting only, not as primary vertigo treatment 6

Medication Dosing and Safety

Meclizine (FDA-Approved for Vertigo)

• Dosage: 25-100 mg daily in divided doses 3, 8
• Use PRN rather than scheduled to promote vestibular compensation 6
• FDA indication: Treatment of vertigo associated with vestibular system diseases 8

Critical warnings for meclizine:

• Significant fall risk, especially in elderly patients 2, 3, 6
• Anticholinergic effects: drowsiness, cognitive deficits, dry mouth, blurred vision, urinary retention 2, 8
• Use with caution in patients with asthma, glaucoma, or prostate enlargement 3, 8
• Impairs driving and operating machinery 3, 8
• Drug interactions with other CNS depressants and CYP2D6 inhibitors 8

Prochlorperazine

• Dosage: 5-10 mg orally or IV, maximum 3 doses per 24 hours 6
• Use only for severe nausea/vomiting, not as primary vertigo treatment 6
• Caution with CNS depression or adrenergic blockers 6

Vestibular Rehabilitation

Vestibular rehabilitation is indicated for persistent dizziness, chronic imbalance, or incomplete recovery from any vestibular cause. 3, 6

• Can be self-administered or therapist-directed 1, 3
• Promotes central compensation and long-term recovery 3, 6
• Should replace medications as soon as acute symptoms improve 6

Critical Pitfalls to Avoid

Do NOT prescribe meclizine as primary treatment for BPPV—this is explicitly contraindicated by guidelines and has poor efficacy compared to repositioning maneuvers 1, 2

Do NOT use vestibular suppressants long-term—they interfere with central compensation and increase fall risk 2, 6, 7

Do NOT skip reassessment—patients must be reevaluated within 1 month to document resolution or identify treatment failures 1, 3, 6

Elderly patients require special caution with vestibular suppressants due to anticholinergic burden, fall risk, and polypharmacy concerns 2, 3

Red flags requiring imaging: atypical nystagmus patterns, neurological signs, or lack of response to appropriate treatment 3

Follow-Up and Monitoring

• Reassess within 1 month after initial treatment to document symptom resolution or persistence 1, 3, 6
• Discontinue vestibular suppressants as soon as possible 2, 6
• Transition to vestibular rehabilitation when appropriate for long-term recovery 3, 6
• Counsel patients on fall risk, potential recurrence, and importance of follow-up 1, 3
• For Ménière's disease, monitor hearing loss progression and quality of life 1