What are the treatment options for vertigo?

Treatment of Vertigo

The treatment of vertigo depends entirely on the underlying cause, with benign paroxysmal positional vertigo (BPPV) requiring canalith repositioning procedures as first-line therapy, while vestibular suppressant medications should be avoided as routine treatment.

BPPV: The Most Common Cause

First-Line Treatment: Canalith Repositioning Procedures

For posterior canal BPPV (85-95% of cases), perform the Epley maneuver immediately—this achieves 80% success with 1-3 treatments and 90-98% with repeat maneuvers if needed. 1, 2, 3

The Epley maneuver involves:

• Patient seated with head turned 45° toward affected ear 2
• Rapidly move to supine with head hanging 20° below horizontal 2
• Turn head 90° to unaffected side 2
• Turn head and body another 90° (face down) 2
• Return to sitting 2

For lateral (horizontal) canal BPPV (10-15% of cases), use the Gufoni maneuver (93% success rate) or barbecue roll maneuver (75-90% effectiveness). 1, 2, 3

Critical Post-Treatment Instructions

Patients can resume normal activities immediately—postprocedural restrictions provide no benefit and may cause unnecessary complications. 2, 3

Reassess all patients within 1 month to confirm symptom resolution. 4, 1, 3

Medication Management: What NOT to Do

Do not routinely prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV—there is no evidence they work as definitive treatment and they cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk, and interference with central compensation. 4, 2, 3

The only exception: Consider vestibular suppressants for short-term management (hours to days) of severe nausea/vomiting in severely symptomatic patients refusing other treatment or requiring prophylaxis immediately before/after repositioning procedures. 2, 3

Meclizine is FDA-approved for "vertigo associated with diseases affecting the vestibular system" but causes drowsiness and has anticholinergic effects, requiring caution in patients with asthma, glaucoma, or prostate enlargement. 5

Vestibular Rehabilitation Therapy

Offer VRT as adjunctive therapy (not as substitute for repositioning procedures), particularly for patients with residual dizziness, postural instability, or heightened fall risk after successful repositioning. 1, 2

VRT includes:

• Habituation exercises to reduce symptom provocation 1
• Adaptation exercises for gaze stabilization 1
• Compensation exercises for vestibular deficits 1

Brandt-Daroff exercises are significantly less effective than repositioning procedures (24% vs 71-74% success at 1 week) but may be used for patients with physical limitations preventing standard maneuvers. 1, 2

Self-Treatment Options

Teach motivated patients self-administered Epley maneuver after at least one properly performed in-office treatment—this achieves 64% improvement compared to only 23% with Brandt-Daroff exercises. 1, 2

Management of Treatment Failures

If symptoms persist after initial treatment:

Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV—repeat repositioning achieves 90-98% success rates. 1, 2, 3

Evaluate for:

• Canal conversion (occurs in ~6% of cases)—the affected canal may change during treatment 1, 2, 3
• Multiple canal involvement 2
• Coexisting vestibular dysfunction if symptoms occur with general head movements or spontaneously 2
• CNS disorders masquerading as BPPV if atypical features present 2

Special Populations Requiring Modified Approach

Assess all patients before treatment for contraindications including severe cervical stenosis, cervical radiculopathy, Down syndrome, severe rheumatoid arthritis, morbid obesity, Paget's disease, or spinal cord injuries. 4, 2

Elderly patients with BPPV warrant particular attention—they have higher risk for falls, depression, and impaired daily activities. 2 Studies show 9% of patients in geriatric clinics have undiagnosed BPPV, with three-quarters having fallen within the previous 3 months. 2

For patients with contraindications, consider Brandt-Daroff exercises or refer to specialized vestibular physical therapy. 2

Other Causes of Vertigo

Vestibular Neuritis/Labyrinthitis

Initial treatment includes vestibular suppressants for acute symptom control (days, not weeks), followed by vestibular rehabilitation exercises. 6, 7

Ménière's Disease

Treatment goals include reducing severity and frequency of vertigo attacks through salt restriction and diuretics. 1, 7 Non-ablative procedures are preferred for patients with usable hearing. 1

Vertiginous Migraine

Generally improves with dietary changes, tricyclic antidepressants, and beta blockers or calcium channel blockers. 6

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers for BPPV 3
• Failing to reassess patients after initial treatment 3
• Missing canal conversions or multiple canal involvement 3
• Not performing maneuvers quickly enough during execution reduces effectiveness 2
• Treating the wrong canal—always confirm diagnosis with proper testing first 2