What are the treatment options for chronic vertigo?

Treatment of Chronic Vertigo

For chronic vertigo, vestibular rehabilitation therapy is the primary treatment, while vestibular suppressant medications (antihistamines, benzodiazepines) should be avoided or discontinued as they impede central compensation and worsen long-term outcomes. 1, 2

Understanding Chronic vs. Acute Vertigo

The approach to chronic vertigo fundamentally differs from acute vertigo management. First, establish whether you're dealing with:

• Persistent symptoms from an underlying condition (BPPV, Ménière's disease, vestibular migraine) that requires specific treatment 1, 2
• True chronic imbalance after the acute phase has resolved, requiring rehabilitation 1

Identify and Treat the Underlying Cause

If BPPV is Present

• Perform canalith repositioning procedures (Epley maneuver for posterior canal, Barbecue Roll for horizontal canal) with 80-98% success rates 3
• Do NOT use medications as primary treatment for BPPV 1, 3

If Ménière's Disease is Present

• Offer vestibular rehabilitation for chronic interictal instability between attacks 1
• Use salt restriction and diuretics for prevention 1, 4
• Reserve vestibular suppressants only for acute attacks, not chronic management 1
• Consider intratympanic gentamicin for inadequate vertigo control 1

If Vestibular Migraine is Present

• Use prophylactic agents: calcium channel antagonists, tricyclic antidepressants, or beta-blockers 4, 5

Primary Treatment: Vestibular Rehabilitation

Vestibular rehabilitation therapy should be offered to all patients with chronic imbalance including those with:

• Residual dizziness after successful BPPV treatment 1
• Bilateral Ménière's disease 1
• Following ablative therapy 1
• Impaired central vestibular compensation 2

Benefits include improved symptom control, reduced fall risk, improved confidence, and enhanced quality of life 1

Medication Management: What NOT to Do

Vestibular suppressants (meclizine, antihistamines, benzodiazepines) should be reduced or stopped in chronic vertigo because they:

• Delay rather than enhance vestibular compensation 1, 6, 2
• Cause drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 7, 8
• Have no evidence supporting efficacy as definitive treatment 1
• Interfere with the brain's natural adaptation mechanisms 7

Very Limited Exceptions for Short-Term Medication Use

Vestibular suppressants may be considered only for:

• Severe nausea/vomiting during acute exacerbations 7
• Patients refusing other treatment options 1
• Short-term management while arranging definitive treatment 7

Meclizine dosing (if absolutely necessary): 25-100 mg daily in divided doses, used as-needed rather than scheduled 7, 8

Address Impediments to Compensation

Chronic dizziness often persists because compensation is blocked by:

• Visual problems: cataracts, recent cataract surgery, squints 2
• Proprioceptive deficits: diabetic neuropathy, alcohol-related neuropathy 2
• Mobility limitations: orthopedic problems, fear of falling 2
• Psychological factors: anxiety, panic disorder, agoraphobia 4, 2
• Continued use of vestibular suppressants 2

Each of these must be identified and addressed for successful rehabilitation 2

Treatment Algorithm for Chronic Vertigo

1. Establish retrospective diagnosis: Determine if symptoms started as BPPV, vestibular neuritis, Ménière's disease, or migraine 2

2. Determine if original condition is still active:

   • If yes → treat the underlying condition specifically 2
   • If no → proceed to rehabilitation 2

3. Identify and address impediments to compensation (visual, proprioceptive, mobility, psychological) 2

4. Discontinue vestibular suppressants if currently prescribed 2

5. Initiate vestibular rehabilitation therapy as primary treatment 1, 2

6. Reassess within 1 month to document improvement or need for additional interventions 7

Common Pitfalls to Avoid

• Continuing vestibular suppressants long-term: This is the most common error and actively prevents recovery 1, 2
• Failing to identify persistent BPPV: Many patients labeled as "chronic vertigo" actually have untreated BPPV that would respond to repositioning 3
• Not addressing psychological comorbidities: Anxiety and fear of falling perpetuate symptoms and require specific treatment 4, 2
• Prescribing meclizine to elderly patients: This significantly increases fall risk and cognitive impairment 7

Special Populations

Elderly patients warrant particular attention as they:

• Have higher risk for falls, depression, and impaired daily activities with chronic vertigo 3
• Are more susceptible to anticholinergic side effects from medications 7
• Benefit most from vestibular rehabilitation and fall prevention strategies 1