What is the difference in treatment for disequilibrium vs vertigo?

Treatment Differences: Disequilibrium vs Vertigo

Vertigo requires canalith repositioning procedures (not medications) for BPPV, while disequilibrium requires vestibular rehabilitation therapy focused on balance and gait training—these are fundamentally different treatment approaches for distinct pathophysiological conditions. 1, 2

Understanding the Core Distinction

Vertigo is an illusion of rotational motion caused by asymmetrical vestibular input to the brainstem, most commonly from BPPV (85-95% of cases), Ménière's disease, or vestibular neuritis 1, 3. Disequilibrium is a sensation of imbalance or unsteadiness without the spinning sensation, often resulting from multiple sensory deficits, central nervous system disorders, or residual symptoms after vestibular injury 3, 4.

Treatment Algorithm for Vertigo

For BPPV (Most Common Cause)

• Perform canalith repositioning procedures immediately as first-line treatment, with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers 1, 2, 5
• Epley maneuver for posterior canal BPPV (85-95% of cases): patient sits upright with head turned 45° toward affected ear, rapidly lay back to supine head-hanging 20° position for 20-30 seconds, turn head 90° toward unaffected side, roll patient onto side, then return to sitting 2, 5
• Barbecue Roll maneuver for horizontal canal BPPV (10-15% of cases): roll patient 360° in sequential 90° steps 2, 5
• Do NOT prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) as primary treatment—they show only 30.8% improvement versus 78.6-93.3% with repositioning procedures 1, 2, 5
• No postprocedural restrictions are needed after successful repositioning 1, 2, 5

For Ménière's Disease

• Limited course of vestibular suppressants (meclizine 25-100 mg daily divided) for acute attacks only, not chronic use 1, 2
• Dietary sodium restriction and diuretics to prevent flare-ups 1, 2, 6
• Consider intratympanic steroids for refractory cases 1

For Vestibular Neuritis

• Brief vestibular suppressants (2-3 days maximum) for severe acute symptoms only 6, 7
• Transition rapidly to vestibular rehabilitation to promote compensation 6, 7

Treatment Algorithm for Disequilibrium

Primary Intervention

• Vestibular rehabilitation therapy is the definitive treatment for disequilibrium, focusing on habituation exercises, gaze stabilization, and balance training 2, 8, 4
• Habituation exercises expose patients to movements that provoke symptoms to promote central compensation 2, 8
• Adaptation exercises for gaze stabilization during head movements 2
• Balance and gait training to address postural instability 2, 8, 4

When Medications Are Considered

• Avoid vestibular suppressants as they interfere with central compensation and prolong recovery 2, 8, 9
• Betahistine (16-48 mg three times daily) may help specific subgroups (age >50, hypertension, symptom onset <1 month), though evidence is mixed 2, 8
• Discontinue benzodiazepines immediately if already prescribed—they are a significant independent risk factor for falls 8

Critical Distinctions in Management

Vertigo Treatment Pitfalls

• Never use medications as primary treatment for BPPV—this delays definitive cure and exposes patients to unnecessary side effects including drowsiness, cognitive deficits, and 12-fold increased fall risk 1, 2, 5
• Vestibular suppressants delay compensation in peripheral vestibular disorders 2, 8, 9
• Reassess within 1 month if symptoms persist—consider canal conversion (6% of cases), multiple canal involvement, or central causes 2, 5, 8

Disequilibrium Treatment Pitfalls

• Do not prescribe long-term vestibular suppressants—they interfere with the brain's ability to compensate for vestibular deficits 2, 8, 9
• Elderly patients are particularly vulnerable to anticholinergic side effects, falls, and cognitive dysfunction from medications 2, 8
• Address polypharmacy—fall risk increases exponentially with multiple medications 8

Special Populations

Elderly Patients

• Assess fall risk immediately in all elderly patients with either vertigo or disequilibrium—BPPV increases fall risk 12-fold 5
• Avoid meclizine and benzodiazepines due to anticholinergic burden, cognitive impairment, and fall risk 2, 8
• Prioritize vestibular rehabilitation over medications for both conditions 2, 8

Patients with Physical Limitations

• Modified approaches may be needed for cervical stenosis, severe rheumatoid arthritis, or morbid obesity 2, 5
• Brandt-Daroff exercises (less effective but safer) can substitute for repositioning maneuvers in patients with contraindications 2, 5

Follow-Up Protocol

• Reassess all patients within 1 month to document symptom resolution or persistence 2, 5, 8
• Transition from acute management to rehabilitation as soon as severe symptoms subside 2, 8
• For treatment failures, repeat diagnostic testing to confirm persistent pathology versus need for alternative diagnosis 2, 5, 8