What are the guidelines for treating vertigo?

Guidelines for Treating Vertigo

Diagnosis First: Identify the Type of Vertigo

The American Academy of Otolaryngology-Head and Neck Surgery recommends classifying vertigo into three vestibular syndromes based on timing and triggers: triggered episodic (positional), spontaneous episodic, or acute vestibular syndrome 1.

Diagnostic Maneuvers

• Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20° 2.
• Posterior canal BPPV is confirmed when torsional, upbeating nystagmus is provoked 2, 1.
• If the Dix-Hallpike test is negative but history suggests BPPV, perform the supine roll test to assess for lateral semicircular canal BPPV 2.

What NOT to Do for Diagnosis

• Do not obtain radiographic imaging in patients who meet diagnostic criteria for BPPV unless additional signs/symptoms inconsistent with BPPV are present 2.
• Do not order vestibular testing in patients with confirmed BPPV unless additional vestibular signs warrant testing 2.

Treatment Algorithm

For Posterior Canal BPPV (Most Common)

Clinicians should treat posterior canal BPPV with a canalith repositioning procedure (Epley or Semont maneuver) as first-line therapy 2, 3.

• Success rates are 90-98% when performed correctly 3, 1.
• Do not recommend postprocedural postural restrictions after the canalith repositioning procedure 2.
• Observation with follow-up may be offered as an alternative initial management option 2.

For Lateral Canal BPPV

• Use the Gufoni maneuver or barbecue roll maneuver, which has an 86-100% success rate 3.

Vestibular Rehabilitation Therapy

• May offer vestibular rehabilitation (either self-administered or with a clinician) as an alternative or adjunct to repositioning maneuvers 2, 3.
• VRT includes Cawthorne-Cooksey exercises and Brandt-Daroff exercises performed until symptoms fatigue 3.
• Home-based therapy appears equally effective as clinician-supervised therapy 3.

What NOT to Use for Treatment

Do not routinely treat BPPV with vestibular suppressant medications such as antihistamines (meclizine) or benzodiazepines 2.

• While meclizine is FDA-approved for vertigo associated with vestibular system diseases 4, guidelines strongly recommend against its routine use in BPPV 2.
• Benzodiazepines impede central vestibular compensation and should be avoided 1.
• These medications may be considered only for acute spontaneous vertigo (vestibular neuritis) to reduce neurovegetative symptoms, not for BPPV 5.

Follow-Up and Reassessment

Reassess patients within 1 month after initial observation or treatment to document resolution or persistence of symptoms 2, 3.

Treatment Failure Protocol

• If symptoms persist after 2-3 repositioning attempts, evaluate for:

  • Unresolved BPPV or involvement of other semicircular canals 2
  • Underlying peripheral vestibular disorders 2
  • Central nervous system disorders 2

• Approximately 3% of BPPV treatment failures have underlying CNS disorders 1.

• Canal conversion occurs in approximately 6% of cases and requires repositioning for the newly affected canal 3.

Red Flags Requiring Neuroimaging

Order MRI of brain and posterior fossa if patients demonstrate 2, 1:

• Atypical nystagmus patterns (downbeating on Dix-Hallpike, direction-changing without head position changes, gaze-evoked nystagmus)
• Associated neurologic symptoms (dysarthria, dysmetria, dysphagia, sensory/motor deficits, Horner's syndrome)
• No improvement after 2-3 repositioning attempts
• Approximately 10% of cerebellar strokes present similarly to peripheral vestibular disorders 1

Risk Assessment and Patient Education

Assess patients for modifying factors including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling 2.

• Older adults with dizziness have a 12-fold increased fall risk 1.
• Educate patients regarding BPPV's impact on safety, potential for recurrence (15% per year, up to 50% at 5 years), and importance of follow-up 2.

Common Pitfalls to Avoid

• Do not use vestibular suppressants as routine treatment—they interfere with compensation and are not indicated for BPPV 2, 1.
• Do not order unnecessary imaging or vestibular testing in straightforward BPPV cases 2.
• Do not assume treatment failure means BPPV—reevaluate for central causes after 2-3 failed attempts 2, 1.
• Do not forget to check for lateral canal involvement if posterior canal treatment fails 2, 3.