What is the treatment for vertigo?

Treatment for Vertigo

For vertigo treatment, use vestibular suppressants like meclizine (25-100 mg daily) only for short-term symptomatic relief during acute episodes, not as definitive therapy, while the primary treatment depends on the underlying cause—canalith repositioning maneuvers for BPPV, dietary modifications with diuretics for Ménière's disease, and vestibular rehabilitation for most other peripheral vestibular disorders. 1, 2

Treatment Approach by Underlying Cause

BPPV (Benign Paroxysmal Positional Vertigo)

• Canalith repositioning maneuvers (Epley maneuver) are first-line treatment with approximately 80% success rates after only 1-3 treatments, far superior to medication alone which shows only 30.8% improvement. 2
• Do not use meclizine or other vestibular suppressants as primary treatment for BPPV—the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against this practice. 2
• Meclizine may only be considered for managing severe nausea/vomiting during repositioning procedures or in patients who refuse other treatments. 2

Ménière's Disease

• Use vestibular suppressants (meclizine or benzodiazepines) only during acute attacks, not as continuous therapy. 1, 2
• Long-term management relies on dietary salt restriction and diuretics, not vestibular suppressants. 1
• For refractory cases with inadequate control despite conservative measures, intratympanic gentamicin injections achieve complete vertigo control in 73.6% of patients, with titration therapy showing the best results at 81.7% control. 3
• Intratympanic steroid therapy combined with oral betahistine shows superior vertigo control (73%) compared to steroids alone (44%). 3

Other Peripheral Vestibular Disorders

• Vestibular rehabilitation is the cornerstone of long-term recovery and should replace medication as soon as acute symptoms subside. 1, 2
• Transition patients from medication to vestibular rehabilitation within 1 month to promote central compensation. 1, 2

Medication Management

Meclizine (First-Line Vestibular Suppressant)

• FDA-approved dosage: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases. 4
• Use as-needed (PRN) rather than scheduled dosing to avoid interfering with vestibular compensation. 1, 2
• Works by suppressing the central emetic center. 1
• Common side effects include drowsiness, cognitive deficits, and anticholinergic effects (dry mouth, blurred vision, urinary retention). 4

Prochlorperazine

• Use only for short-term management of severe nausea/vomiting, not as primary vertigo treatment. 1, 2
• Typical dosage: 5-10 mg orally or intravenously, maximum three doses per 24 hours. 1

Benzodiazepines

• May be used short-term for severe vertigo symptoms and psychological anxiety secondary to vertigo. 1
• Avoid for motion sickness due to lack of efficacy and significant harm potential. 5

Betahistine

• The 2020 BEMED trial showed no significant benefit over placebo in reducing vertigo attack frequency over 9 months in Ménière's disease patients. 1
• However, when combined with intratympanic steroids for Ménière's disease, betahistine improved vertigo control from 44% to 73%. 3
• Some older studies suggest potential benefit at 48 mg daily for 3 months in peripheral vertigo, but this is not supported by the most recent high-quality evidence. 6, 7, 8

Critical Safety Warnings

Fall Risk and Elderly Patients

• Vestibular suppressants are a significant independent risk factor for falls, especially in elderly patients. 1, 2
• Do not routinely prescribe meclizine for elderly patients with dizziness due to fall risk, anticholinergic burden, and lack of efficacy for common causes like BPPV. 2

Interference with Vestibular Compensation

• Long-term use of vestibular suppressants interferes with central compensation in peripheral vestibular conditions. 1, 5, 2
• This delays natural recovery and prolongs disability. 1

Contraindications

• Hypersensitivity to meclizine or inactive ingredients. 4
• Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects. 4
• Avoid driving or operating machinery while taking meclizine due to drowsiness. 4

Lifestyle Modifications (Essential Adjunct)

• Limit salt/sodium intake (especially critical for Ménière's disease). 1, 2
• Avoid excessive caffeine, alcohol, and nicotine. 1, 2
• Maintain adequate hydration, regular exercise, and sufficient sleep. 1
• Manage stress appropriately. 1, 2

Follow-Up Protocol

• Reassess all patients within 1 month to document symptom resolution or persistence. 1, 2
• Discontinue vestibular suppressants as soon as possible. 2
• Transition to vestibular rehabilitation when appropriate for long-term recovery. 1, 2

Common Pitfalls to Avoid

• Never use meclizine as primary treatment for BPPV—this is ineffective and delays proper treatment with repositioning maneuvers. 2
• Never prescribe vestibular suppressants on a scheduled, long-term basis—this interferes with natural compensation mechanisms. 1, 2
• Do not overlook fall risk in elderly patients—anticholinergic medications significantly increase this risk. 1, 2
• Do not rely on betahistine for Ménière's disease—the most recent high-quality trial showed no benefit over placebo. 1