What are the treatment options for a patient experiencing vertigo?

Treatment of Vertigo

For patients experiencing vertigo, the treatment approach depends entirely on the underlying cause: benign paroxysmal positional vertigo (BPPV) requires canalith repositioning procedures as definitive treatment, while Ménière's disease requires dietary sodium restriction combined with diuretics, and vestibular neuronitis requires initial vestibular suppressants followed by rehabilitation—medications like meclizine should NOT be used as primary treatment for BPPV despite being commonly prescribed. 1, 2, 3

Diagnostic Framework: Identify the Specific Cause

Before treating vertigo, you must determine which condition is causing it, as treatment differs dramatically:

• BPPV (most common, 85-95% of peripheral vertigo): Diagnosed by positive Dix-Hallpike test showing torsional upbeating nystagmus for posterior canal involvement, or supine roll test for lateral canal involvement 1, 2
• Ménière's disease: Characterized by episodic vertigo with fluctuating hearing loss, tinnitus, and aural fullness 1
• Vestibular neuronitis: Single prolonged episode of spontaneous vertigo lasting days, without hearing loss 4, 5

Treatment Algorithm by Diagnosis

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

The Epley maneuver is the definitive first-line treatment with 80-93% success rates after 1-3 treatments: 2, 6

1. Perform the Epley maneuver immediately at the visit—this involves positioning the patient upright with head turned 45° toward the affected ear, rapidly laying back to supine head-hanging 20° position for 20-30 seconds, turning head 90° toward unaffected side, rolling patient onto side, and returning to upright position 2, 6

2. Do NOT prescribe postprocedural restrictions—patients can resume normal activities immediately, as restrictions provide no benefit and may cause unnecessary complications 1, 2

3. Do NOT prescribe meclizine or other vestibular suppressants as primary treatment—these have no evidence of effectiveness for BPPV (30.8% vs 78.6-93.3% for repositioning maneuvers) and cause drowsiness, cognitive deficits, and increased fall risk 1, 2, 3

4. Reassess within 1 month to confirm symptom resolution 1, 2

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

• Geotropic variant: Use Barbecue Roll (Lempert) maneuver (50-100% success rate) or Gufoni maneuver (93% success rate) 2, 3
• Apogeotropic variant: Use Modified Gufoni maneuver (patient lies on affected side) 2, 3

For Ménière's Disease

First-line preventive therapy combines dietary and medical management: 3

1. Dietary sodium restriction to 1500-2300 mg daily 3
2. Diuretics for long-term management 3
3. Limit alcohol and caffeine intake 3
4. For acute vertigo attacks: Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) for symptom relief only 3, 7
5. Consider betahistine to increase inner ear vasodilation 3
6. Document outcomes: Track resolution or worsening of vertigo, tinnitus, hearing loss, and quality of life changes after treatment 1

For Vestibular Neuronitis

1. Initial phase (first 24-72 hours): Vestibular suppressants for symptom control 5, 8
2. Recovery phase: Discontinue suppressants and begin vestibular rehabilitation exercises to promote central compensation 5

Vestibular Rehabilitation Therapy (VRT)

VRT should be offered as adjunctive therapy, NOT as substitute for repositioning procedures in BPPV: 3, 6

• Indications: Persistent dizziness after successful BPPV treatment, postural instability, heightened fall risk, or chronic imbalance from any vestibular cause 3, 6
• Components: Habituation exercises, adaptation exercises for gaze stabilization, and compensation exercises 2, 3
• Brandt-Daroff exercises: Less effective than repositioning maneuvers (24% vs 71-74% success at 1 week) but useful for patients with contraindications to repositioning 2, 3
• Effectiveness: Patients treated with repositioning plus VRT show significantly improved gait stability compared to repositioning alone 3

Critical Medication Guidance

Meclizine and other vestibular suppressants have a very limited role in vertigo treatment: 1, 2, 3, 7

• Approved indication: Treatment of vertigo associated with vestibular system diseases (FDA-approved dosage: 25-100 mg daily in divided doses) 7
• When to use: Only for severe nausea/vomiting during acute Ménière's attacks or vestibular neuronitis—maximum 3-5 days 3
• When NOT to use: As primary treatment for BPPV, as these medications do not reposition displaced otoconia and interfere with central compensation mechanisms 1, 2, 3
• Adverse effects: Drowsiness, cognitive deficits, anticholinergic effects, increased fall risk (especially in elderly), and driving impairment 3, 7
• Contraindications: Asthma, glaucoma, prostate enlargement 3, 7

Management of Treatment Failures

If symptoms persist after initial BPPV treatment: 2, 3, 6

1. Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV 2
2. Perform additional repositioning maneuvers—repeat treatments achieve 90-98% success rates 2, 6
3. Check for canal conversion (occurs in 6-7% of cases)—posterior canal may convert to lateral canal or vice versa 2, 3
4. Evaluate for multiple canal involvement or bilateral BPPV 2, 3
5. Rule out coexisting vestibular pathology if symptoms occur with general head movements or spontaneously 2
6. Consider CNS disorders if atypical features present (downbeating nystagmus, direction-changing nystagmus without position changes, lack of response to repositioning) 2, 3

Special Populations and Contraindications

Assess all patients before treatment for modifying factors: 1, 2, 3

• Contraindications to repositioning maneuvers: Severe cervical stenosis or radiculopathy, severe rheumatoid arthritis, ankylosing spondylitis, severe kyphoscoliosis, morbid obesity, Down syndrome, Paget's disease, retinal detachment, spinal cord injuries 2, 3
• Alternative for contraindicated patients: Brandt-Daroff exercises or referral to specialized vestibular physical therapy 2, 3
• Elderly patients: At 12-fold increased fall risk with BPPV—address home safety, activity restrictions, and need for supervision immediately 2, 3

Self-Treatment Options

Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment: 2, 3

• Effectiveness: 64% improvement with self-administered repositioning vs 23% with Brandt-Daroff exercises 2, 3
• Requirement: Initial instruction by clinician is essential 2

Common Pitfalls to Avoid

• Prescribing meclizine for BPPV as primary treatment—this is the most common error and delays definitive cure 1, 2, 3
• Imposing postprocedural restrictions after Epley maneuver—these provide no benefit 1, 2
• Failing to identify the affected canal before treatment leads to ineffective therapy 2
• Not reassessing within 1 month can lead to persistent untreated symptoms 1, 2
• Ordering imaging or vestibular testing in straightforward BPPV cases—these are unnecessary unless atypical features present 1, 3
• Not moving the patient quickly enough during repositioning maneuvers reduces effectiveness 2

Recurrence Management

BPPV has inherently high recurrence rates: 2

• 10-18% recurrence at 1 year, 30-50% at 5 years 2
• Each recurrence should be treated with repeat repositioning—maintains same 90-98% success rates 2
• Adding vestibular rehabilitation after successful repositioning reduces future recurrence rates by approximately 50% 2