What are the treatment options for vertigo?

Treatment of Vertigo

First-Line Treatment: Canalith Repositioning Procedures

The Epley maneuver is the definitive first-line treatment for posterior canal BPPV (which accounts for 85-95% of vertigo cases), with success rates of 90-98% when performed correctly, and should be performed immediately without any medication. 1, 2, 3

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases):

• Perform the Epley maneuver as primary treatment 1, 2, 3
• The technique involves: patient seated with head turned 45° toward affected ear → rapidly move to supine with head hanging 20° below horizontal → turn head 90° to unaffected side → turn head and body another 90° (face down) → return to sitting 3
• Success rate: 80% after 1-3 treatments, 90-98% with repeat maneuvers if needed 2, 3
• Alternative: Semont (Liberatory) maneuver with 94.2% resolution at 6 months 2

Lateral (Horizontal) Canal BPPV (10-15% of cases):

• For geotropic variant: Gufoni maneuver (93% success) or Barbecue Roll/Lempert maneuver (75-100% success) 1, 2, 3
• For apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side) 2

Diagnosis Before Treatment

• Posterior canal: Dix-Hallpike test provokes torsional, upbeating nystagmus 2, 3
• Lateral canal: Supine roll test shows geotropic or apogeotropic horizontal nystagmus 2, 3

Critical Post-Treatment Instructions

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

• Reassess within 1 month to confirm symptom resolution 1, 3
• Mild residual symptoms may persist for days to weeks after successful treatment 2

Medication Management: What NOT to Do

Vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) should NOT be routinely prescribed for BPPV treatment—they have no evidence of effectiveness as definitive treatment and cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk, and interference with central compensation mechanisms. 1, 2, 3

Limited Role for Medications

• Consider vestibular suppressants ONLY for short-term management of severe nausea/vomiting in severely symptomatic patients refusing other treatment 2, 3
• Meclizine FDA-approved dosing: 25-100 mg daily in divided doses for vertigo associated with vestibular disease 4
• However, guideline evidence strongly recommends against routine use despite FDA approval 1, 2, 3

Common Pitfall to Avoid

Relying on medications instead of repositioning maneuvers is the most common treatment error. 3

Vestibular Rehabilitation Therapy (VRT)

VRT should be offered as adjunctive therapy after successful repositioning, NOT as a substitute for canalith repositioning procedures. 1, 2, 3

When to Use VRT

• Particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful repositioning 2, 3
• Reduces recurrence rates by approximately 50% when added after successful repositioning 2
• Patients treated with repositioning plus VRT show significantly improved gait stability compared to repositioning alone 2

VRT Components

• Habituation exercises: Cawthorne-Cooksey exercises performed until symptoms fatigue 1
• Adaptation exercises for gaze stabilization 2
• Brandt-Daroff exercises: significantly less effective than repositioning (24-25% vs 71-80% success at 1 week) but may be used for patients with physical limitations 1, 2

Self-Treatment Options

Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment, with 64% improvement compared to 23% with Brandt-Daroff exercises. 2, 3

Management of Treatment Failures

If symptoms persist after initial treatment, repeat the diagnostic test and perform additional repositioning maneuvers—success rates reach 90-98% with repeat treatments. 2, 3

Reassessment Protocol

• Confirm persistent BPPV with repeat Dix-Hallpike or supine roll test 2
• Check for canal conversion (occurs in 6-7% of cases—posterior may convert to lateral or vice versa) 1, 2, 3
• Evaluate for multiple canal involvement or bilateral BPPV 2
• Rule out coexisting vestibular pathology if symptoms occur with general head movements or spontaneously 2
• Consider CNS disorders masquerading as BPPV if atypical features present 2, 3

Special Populations Requiring Modified Approach

Assess all patients before treatment for contraindications including severe cervical stenosis, cervical radiculopathy, severe rheumatoid arthritis, morbid obesity, or spinal cord injuries. 2, 3

• For patients with contraindications: consider Brandt-Daroff exercises or specialized vestibular physical therapy 2
• Elderly patients warrant particular attention due to 12-fold increased fall risk with BPPV 2
• 9% of patients in geriatric clinics have undiagnosed BPPV, with three-quarters having fallen within 3 months 2

Treatment of Other Vertigo Causes

Ménière's Disease

• Treatment goals: reduce severity/frequency of vertigo attacks, relieve associated symptoms, improve quality of life 1
• Low-salt diet combined with diuretics 5
• Non-ablative procedures preferred for patients with usable hearing 1

Vestibular Neuronitis/Labyrinthitis

• Initial stabilizing measures with vestibular suppressant medication (appropriate for this condition, unlike BPPV) 5
• Followed by vestibular rehabilitation exercises 5

Vertiginous Migraine

• Dietary changes, tricyclic antidepressant, beta blocker or calcium channel blocker 5

Recurrence Management

• BPPV has high recurrence rates: 10-18% at 1 year, 30-50% at 5 years, estimated 15% per year 2
• Each recurrence treated with repeat repositioning maintains same 90-98% success rates 2
• Adding VRT after successful repositioning reduces future recurrence by approximately 50% 2