What is the recommended treatment for vertigo?

Treatment of Vertigo

First-Line Treatment: Diagnosis-Specific Approach

For benign paroxysmal positional vertigo (BPPV), particle repositioning maneuvers are the definitive treatment and medications should NOT be used as primary therapy. 1, 2

BPPV Management

• Perform canalith repositioning procedures (Epley or Semont maneuvers) as first-line treatment, achieving 80% success rates after 1-3 treatments 2, 3
• Diagnose posterior canal BPPV when vertigo with nystagmus is provoked by the Dix-Hallpike maneuver 1
• If Dix-Hallpike is negative but history suggests BPPV, perform supine roll test to assess for lateral canal BPPV 1
• Do NOT routinely prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) for BPPV treatment—they do not address the underlying cause and may delay recovery 1, 2, 3

Common Pitfall: Prescribing meclizine as primary BPPV treatment is inappropriate and delays definitive care. Studies show repositioning maneuvers achieve 78.6%-93.3% improvement versus only 30.8% with medication alone 3

Limited Medication Role in BPPV

Medications may only be considered for:

• Short-term management of severe nausea/vomiting during acute symptoms 2, 3
• Prophylaxis before repositioning maneuvers in patients with history of severe nausea 3
• Patients who refuse repositioning procedures 3

Non-BPPV Peripheral Vertigo (Ménière's Disease, Vestibular Neuritis)

• Use vestibular suppressants ONLY during acute attacks for short-term symptom relief, not as continuous therapy 2, 3, 4
• Meclizine 25-100 mg daily in divided doses, prescribed as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 2, 3, 5
• Benzodiazepines (e.g., diazepam 5-10 mg) for severe vertigo and associated anxiety 2, 4
• Prochlorperazine for severe nausea/vomiting, maximum three doses per 24 hours 4

For Ménière's disease specifically: Dietary salt restriction and diuretics are the mainstay of prevention, not medications 2, 3, 4

Medication Safety Considerations

Critical Warnings

• Vestibular suppressants cause drowsiness, cognitive deficits, and significantly increase fall risk, especially in elderly patients 2, 3, 4, 5
• Prolonged use interferes with central vestibular compensation and delays recovery 2, 4
• Meclizine has anticholinergic effects: use with caution in patients with asthma, glaucoma, or prostate enlargement 5
• Avoid driving or operating machinery while taking these medications 5

Specific Medication Dosing

Meclizine (FDA-approved for vertigo):

• Dosage: 25-100 mg daily in divided doses 5
• Use PRN rather than scheduled 2, 3
• Swallow tablets whole 5

Diazepam:

• 5-10 mg for acute symptoms 4, 6
• Equally effective as meclizine for peripheral vertigo (no significant difference in symptom improvement) 6

Prochlorperazine:

• 5-10 mg orally or IV, maximum three doses per 24 hours 4
• For nausea/vomiting only, not primary vertigo treatment 4

Treatment Algorithm

1. Establish diagnosis through positional testing (Dix-Hallpike, supine roll test) 1
2. If BPPV confirmed: Perform repositioning maneuver immediately; avoid medications unless severe nausea occurs 1, 2, 3
3. If non-BPPV peripheral vertigo: Short-term vestibular suppressant PRN for acute symptoms only 2, 4
4. Reassess within 1 month to confirm symptom resolution 1, 2, 3
5. Transition to vestibular rehabilitation if symptoms persist, discontinue medications to promote compensation 2, 4

Lifestyle Modifications

• Limit salt/sodium intake (especially for Ménière's disease) 2, 3, 4
• Avoid excessive caffeine, alcohol, and nicotine 2, 3, 4
• Maintain adequate hydration and regular exercise 2, 4
• Manage stress appropriately 3, 4

What NOT to Do

• Do not order routine radiographic imaging or vestibular testing for diagnosed BPPV unless diagnosis is uncertain or additional concerning symptoms exist 1
• Do not prescribe scheduled vestibular suppressants for BPPV 1, 2
• Do not continue vestibular suppressants beyond acute symptom management—they delay compensation 2, 4
• Do not use betahistine for Ménière's disease (no proven benefit over placebo) 4