What treatment options are available for persistent vertigo lasting 2-3 months?

Persistent Vertigo for 2-3 Months: Treatment Approach

For vertigo persisting 2-3 months, you must first reevaluate with a Dix-Hallpike test to identify persistent BPPV requiring repeat canalith repositioning procedures, then systematically rule out coexisting vestibular conditions or central causes that may have been missed initially. 1

Immediate Reevaluation Steps

Your first priority is determining why the vertigo persists. Treatment failures after 2-3 months require systematic reevaluation for three critical reasons: 1

• Persistent BPPV may still be present and responsive to additional maneuvers 1
• Coexisting vestibular conditions (Ménière's disease, vestibular migraine, vestibular neuritis) may be present alongside or instead of BPPV 1
• Serious CNS disorders may simulate peripheral vertigo and need urgent identification 1

Diagnostic Algorithm

Step 1: Detailed History Reassessment

Focus on specific timing and triggers rather than vague descriptions: 2

• Brief episodes (seconds to minutes) triggered by head movements suggest persistent BPPV 2
• Constant symptoms lasting days to weeks suggest acute vestibular syndrome (vestibular neuritis, labyrinthitis, or central causes) 2
• Associated hearing loss, tinnitus, or aural fullness suggest Ménière's disease 2
• Headache, photophobia, phonophobia suggest vestibular migraine 2

Step 2: Physical Examination

Repeat the Dix-Hallpike test to confirm or rule out persistent BPPV. 1 If positive, this indicates treatment failure requiring repeat canalith repositioning procedures. 1

Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if symptoms suggest acute vestibular syndrome, though this requires trained practitioners for reliability. 2 Red flags demanding urgent evaluation include: 2, 3

• Focal neurological deficits (dysarthria, dysmetria, dysphagia, sensory/motor loss)
• Sudden hearing loss
• Inability to stand or walk
• Downbeating nystagmus or direction-changing nystagmus
• New severe headache

Step 3: Audiologic Testing

Obtain comprehensive audiologic examination for any patient with persistent vertigo, especially if unilateral, associated with hearing difficulties, or lasting ≥6 months. 1, 2 This distinguishes between labyrinthitis (with hearing loss) and vestibular neuritis (without hearing loss), and identifies Ménière's disease. 4

Step 4: Imaging Decisions

Do NOT routinely order imaging for persistent vertigo unless red flags are present. 2 The diagnostic yield of CT is extremely low (<1%) for isolated dizziness. 2

Order MRI brain without contrast (NOT CT) if any of the following are present: 2, 3

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk factors with acute vestibular syndrome
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Progressive symptoms suggesting mass lesion

Treatment Based on Diagnosis

For Persistent BPPV

Repeat canalith repositioning procedures (Epley maneuver) are the treatment of choice. 1 Success rates reach 90-98% when additional repositioning maneuvers are performed. 1

• Perform multiple sessions if needed 1
• Do NOT use vestibular suppressants (meclizine) for BPPV, as they are unnecessary and delay central compensation 1, 3
• For cases refractory to multiple CRP attempts, surgical options (posterior semicircular canal plugging, singular neurectomy) have >96% success rates, though data quality limits definitive recommendations 1

For Vestibular Neuritis/Labyrinthitis

If diagnosed within 3 days of onset, oral corticosteroids (methylprednisolone 100mg daily for 3 days, then taper over 7-10 days) accelerate recovery of vestibular function. 4

Vestibular suppressants (meclizine, antihistamines, benzodiazepines) should be used sparingly and discontinued after 3 days maximum to avoid impeding central compensation. 4, 3 While meclizine is FDA-approved for vertigo associated with vestibular system diseases 5, prolonged use interferes with compensation mechanisms and increases fall risk. 3

Vestibular rehabilitation therapy is essential after the acute phase to promote central compensation. 4, 6

For Ménière's Disease

• Salt restriction and diuretics are first-line preventive therapy 2, 7, 8
• Vestibular suppressants only for acute attacks, not chronic management 7
• Transtympanic corticosteroid or gentamicin injections for refractory cases 6

For Vestibular Migraine

• Migraine prophylaxis with tricyclic antidepressants, beta-blockers, or calcium channel blockers 2, 7, 8
• Dietary modifications and lifestyle changes 2
• Acute abortive therapy for attacks 8

Critical Management Pitfalls

Do NOT rely on vestibular suppressants as primary long-term treatment. 3 They mask symptoms without addressing underlying pathology, interfere with central compensation, prolong symptoms, and increase fall risk. 3

Do NOT assume normal neurologic exam excludes stroke. 75-80% of patients with posterior circulation infarct from acute vestibular syndrome have no focal neurologic deficits. 2 Approximately 25% of acute vestibular syndrome cases are cerebellar or brainstem stroke, not peripheral disease. 4

Do NOT order CT instead of MRI when stroke is suspected. CT misses most posterior circulation infarcts and has only 20-40% sensitivity for causative pathology in dizziness. 2

Medication Review and Psychiatric Screening

Review all medications, as they are a leading cause of chronic vestibular syndrome, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic drugs. 2

Screen for psychiatric symptoms (anxiety, panic disorder, depression), as these are common causes of chronic dizziness. 2 Benzodiazepines may be useful for psychogenic vertigo, though selective serotonin reuptake inhibitors are preferred for anxiety-associated vertigo. 7, 8

Patient Education and Follow-Up

Counsel patients about: 1

• BPPV recurrence risk (10-18% at 1 year, up to 36% long-term) 1
• Increased fall risk with any vestibular disorder, especially in elderly 1
• Importance of returning promptly if symptoms recur for repeat repositioning procedures 1

Reassess within 1 month after initial treatment to document resolution or identify treatment failures requiring further evaluation. 2, 3