What are the treatment options for vertigo?

Treatment of Vertigo

The Canalith Repositioning Procedure (Epley maneuver) is the definitive first-line treatment for vertigo, as benign paroxysmal positional vertigo (BPPV) accounts for the vast majority of peripheral vertigo cases and achieves 90-98% success rates when performed correctly. 1, 2, 3

Diagnostic Approach: Identify the Canal Involved

Before treating, you must determine which semicircular canal is affected:

• Perform the Dix-Hallpike maneuver for posterior canal BPPV (85-95% of cases): Bring the patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus 4, 1
• Perform the supine roll test if Dix-Hallpike is negative: Turn the head rapidly 90° to each side while supine, looking for horizontal nystagmus indicating lateral canal BPPV (10-15% of cases) 2, 3

Treatment Algorithm by Canal Type

Posterior Canal BPPV (Most Common)

Execute the Epley maneuver immediately with the following sequence 1, 2, 3:

1. Patient sits upright with head turned 45° toward the affected ear 3
2. Rapidly lay patient back to supine with head hanging 20° below horizontal for 20-30 seconds 2, 3
3. Turn head 90° toward the unaffected side, hold 20-30 seconds 2, 3
4. Roll head and body another 90° (face-down position), hold 20-30 seconds 2, 3
5. Return patient to sitting position 3

Success rate: 80% after 1-3 treatments, 90-98% after repeat maneuvers if needed 1, 2, 3

Lateral (Horizontal) Canal BPPV

Choose between two highly effective maneuvers 1, 2, 3:

• Barbecue Roll (Lempert) maneuver: Roll patient 360° in sequential 90° steps, holding each position 30 seconds (success rate 50-100%) 1, 2, 3
• Gufoni maneuver: For geotropic variant, move patient from sitting to side-lying on unaffected side for 30 seconds, then turn head 45-60° toward ground for 1-2 minutes (success rate 93%) 1, 2

For apogeotropic variant, use the Modified Gufoni maneuver with patient lying on the affected side 2

Critical Post-Treatment Instructions

Do NOT impose postprocedural restrictions—patients can resume normal activities immediately after treatment 2, 3. Strong evidence demonstrates these restrictions provide no benefit and may cause unnecessary complications 2.

Reassess all patients within 1 month to document symptom resolution or persistence 4, 1, 3

Medication Management: What NOT to Do

Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV 2, 3. Despite FDA approval of meclizine for "vertigo associated with diseases affecting the vestibular system" 5, there is no evidence these medications work as definitive treatment for BPPV 2, 3.

These medications cause significant harm 2, 3:

• Drowsiness and cognitive deficits 2, 5
• Increased fall risk, especially in elderly patients 2
• Interference with central compensation mechanisms 2
• Decreased diagnostic sensitivity during examination 2

The only acceptable use for vestibular suppressants is short-term management (days, not weeks) of severe nausea or vomiting in patients who are severely symptomatic 2, 3

Management of Treatment Failures

If symptoms persist after initial Epley maneuver, follow this systematic approach 2, 3:

1. Repeat the diagnostic test to confirm persistent BPPV 2, 3
2. Perform additional repositioning maneuvers—repeat treatments achieve 90-98% success 1, 2, 3
3. Check for canal conversion (occurs in 6% of cases): The affected canal may have changed from posterior to lateral or vice versa 1, 2, 3
4. Evaluate for multiple canal involvement—rare but possible 2
5. Rule out coexisting vestibular pathology if symptoms occur with general head movements or spontaneously 2
6. Consider CNS disorders masquerading as BPPV if atypical features are present (vertical nystagmus, severe neurological signs, inability to walk) 2, 3

Adjunctive Treatment: Vestibular Rehabilitation

Offer vestibular rehabilitation therapy (VRT) as adjunctive therapy, NOT as a substitute for repositioning maneuvers 2, 3. VRT is particularly beneficial for 1, 2:

• Patients with residual dizziness after successful repositioning 2, 3
• Patients with postural instability or heightened fall risk 2, 3
• Elderly patients to reduce recurrence rates (approximately 50% reduction) 2

VRT includes habituation exercises, gaze stabilization exercises, and balance training 1. Patients treated with repositioning plus VRT show significantly improved gait stability compared to repositioning alone 2.

Brandt-Daroff exercises are significantly less effective than repositioning maneuvers (25% vs 80.5% resolution at 7 days) and should only be used for patients with contraindications to standard maneuvers 2, 3

Special Populations Requiring Modified Approach

Assess all patients before treatment for contraindications 2, 3:

• Severe cervical stenosis or radiculopathy 2
• Severe rheumatoid arthritis or ankylosing spondylitis 4
• Morbid obesity 2
• Down syndrome 2
• Severe kyphoscoliosis or limited cervical range of motion 4
• Known cerebrovascular disease 4

For these patients, consider Brandt-Daroff exercises (performed three times daily for 2 weeks) or refer to specialized vestibular physical therapy 2

Self-Treatment Option for Motivated Patients

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

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers—this is the most common error 3
• Failing to reassess patients after initial treatment—symptoms may persist or recur 3
• Missing canal conversions—always retest if symptoms persist 1, 3
• Not addressing fall risk—BPPV increases fall risk 12-fold, particularly in elderly patients 2
• Ordering unnecessary imaging—do not obtain MRI or vestibular testing in patients meeting clinical criteria for BPPV without additional concerning symptoms 2

Recurrent BPPV Management

BPPV has inherently high recurrence rates: 10-18% at 1 year, 30-50% at 5 years 2. Each recurrence should be treated with repeat repositioning, which maintains the same high success rates 2. Adding vestibular rehabilitation after successful repositioning reduces future recurrence by approximately 50% 2.