What are the treatment options for an adult patient with no significant medical history presenting with vertigo?

Treatment of Vertigo in Adults

For an adult with vertigo and no significant medical history, perform the Dix-Hallpike maneuver immediately—if positive for BPPV (the most common cause), treat definitively with the Epley maneuver, which achieves 80-93% success after 1-3 treatments, vastly superior to any medication. 1, 2

Algorithmic Approach to Treatment

Step 1: Classify the Vertigo Pattern to Guide Treatment

The treatment depends entirely on identifying the specific vestibular syndrome based on timing and triggers 1:

• Triggered episodic vertigo (<1 minute): Episodes provoked by specific head position changes suggest BPPV, superior canal dehiscence, or perilymphatic fistula 3
• Spontaneous episodic vertigo (20 minutes to 12 hours): Unprovoked episodes suggest Ménière's disease or vestibular migraine 1, 3
• Acute vestibular syndrome (days): Continuous severe vertigo lasting days indicates vestibular neuritis or labyrinthitis 3
• Chronic vertigo (weeks to months): Persistent symptoms suggest medication effects, anxiety disorder, or posterior fossa mass 3

Step 2: Rule Out Central Causes Before Treating

Before initiating any treatment, check for red flags requiring urgent MRI 1, 2:

• Downbeating nystagmus without torsional component
• Direction-changing nystagmus without head position changes
• Severe postural instability or focal neurologic deficits
• Age >50 with vascular risk factors

If any red flags are present, obtain MRI brain without and with IV contrast urgently before proceeding with treatment 3.

Step 3: Treatment by Specific Diagnosis

BPPV (Most Common—85-95% of Cases)

The Epley maneuver is definitive first-line treatment with 80-93% success after 1-3 treatments 1, 2. This is vastly superior to medications, which show only 30.8% efficacy compared to 78.6-93.3% for repositioning maneuvers 2.

Critical pitfall to avoid: Do not prescribe meclizine as primary treatment for BPPV 2. Meclizine may only be considered for severe nausea/vomiting during the maneuver itself or in patients who refuse repositioning, and should be limited to 3-5 days maximum 2.

Meclizine dosing when indicated: 25-100 mg daily in divided doses 2, 4, but recognize significant adverse effects including drowsiness, cognitive deficits, anticholinergic effects, and increased fall risk, particularly in elderly patients 2.

Contraindications for meclizine: Avoid in patients with asthma, glaucoma, or prostate enlargement 2, 4.

Ménière's Disease

First-line preventive therapy combines dietary sodium restriction (1500-2300 mg daily) with diuretics 1, 2. This addresses the underlying endolymphatic hydrops.

For acute vertigo attacks:

• Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) for symptomatic relief only 2
• Betahistine may be considered to increase inner ear vasodilation 1, 2
• Limit alcohol and caffeine intake 2

Diagnostic criteria: Episodic vertigo lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, or aural fullness 1.

Vestibular Neuritis/Labyrinthitis

For acute vestibular syndrome lasting days:

• Initial vestibular suppressants for symptomatic relief during the acute phase (3-5 days maximum) 2
• Transition to vestibular rehabilitation exercises as soon as tolerated 2

Step 4: Vestibular Rehabilitation for Persistent Symptoms

Vestibular rehabilitation is indicated for 1, 2:

• Persistent dizziness from any vestibular cause
• Chronic imbalance or incomplete recovery
• Can be self-administered or therapist-directed

This applies regardless of the underlying diagnosis when symptoms persist beyond the acute phase.

Step 5: Follow-Up Protocol

Reassess within 1 month after initial treatment to document resolution or persistence 1, 2. During this visit:

• Counsel on fall risk, particularly in elderly patients on vestibular suppressants 2
• Discuss BPPV recurrence rates (if applicable) 1
• Emphasize importance of reporting atypical symptoms 1

If no improvement with repositioning maneuvers or atypical presentation, obtain MRI brain to exclude central causes, as 3% of BPPV treatment failures have CNS disorders masquerading as BPPV 1, 2.

Common Pitfalls to Avoid

• Never use vestibular suppressants as primary treatment for BPPV—they are vastly inferior to the Epley maneuver (30.8% vs 80-93% success) 2
• Do not prescribe meclizine for more than 3-5 days—prolonged use increases fall risk and delays vestibular compensation 2
• Do not assume normal neurologic exam excludes stroke—up to 75-80% of posterior circulation strokes causing vertigo may lack focal neurologic deficits initially 3
• Avoid misdiagnosing central causes as BPPV—if Dix-Hallpike is atypical or treatment fails, obtain MRI 1, 2