From the Guidelines
Vertigo is best managed with the Epley maneuver for benign paroxysmal positional vertigo (BPPV), and patients should seek medical attention if symptoms persist or are accompanied by severe headache, hearing loss, or neurological symptoms. For immediate relief, medications like meclizine (25mg every 6-8 hours as needed), dimenhydrinate (50mg every 4-6 hours), or diazepam (2-5mg twice daily for severe cases) can help manage symptoms 1. During an acute episode, sitting or lying down in a quiet, dark room and avoiding sudden head movements can help alleviate symptoms. The Epley maneuver, a series of head position changes, can effectively relocate displaced inner ear crystals and is a recommended treatment for BPPV 1.
Causes and Diagnosis
Vertigo can result from various inner ear problems, including BPPV, vestibular neuritis, Ménière's disease, or other conditions 1. BPPV is the most common inner ear problem and cause of vertigo, characterized by sudden, short spells of vertigo triggered by position changes 1. The diagnosis of BPPV is typically made through bedside testing, such as the Dix-Hallpike test or supine roll test, which involves moving the patient's head into a position that triggers the vertigo symptoms 1.
Treatment and Management
Treatment for vertigo depends on the underlying cause, but for BPPV, the Epley maneuver is a highly effective treatment with a success rate of around 80% after 1-3 treatments 1. Vestibular rehabilitation exercises can also help retrain the balance system and improve long-term management of vertigo symptoms 1. Patients should stay hydrated and avoid substances that can worsen symptoms, such as alcohol, caffeine, and tobacco. If vertigo persists beyond a few days or is accompanied by severe headache, hearing loss, or neurological symptoms, patients should seek medical attention immediately, as these could indicate more serious conditions 1.
Key Considerations
It is essential to differentiate between peripheral causes of vertigo, such as BPPV, and central causes, such as vestibular migraine, brainstem and cerebellar stroke, or intracranial tumors 1. Failure to respond to conservative management, such as canalith repositioning procedures (CRPs) or vestibular rehabilitation, should raise concern that the underlying diagnosis may not be BPPV 1. Patients with vestibular migraine may experience episodic vestibular symptoms lasting 5 minutes to 72 hours, accompanied by migrainous headache, photophobia, phonophobia, or visual aura 1. Brainstem stroke and cerebellar stroke are dangerous causes of vertigo that require prompt medical attention 1.
From the FDA Drug Label
Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). Recommended dosage: 25 mg to 100 mg daily, in divided doses (2.1).
- Vertigo Treatment: Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults.
- Dosage: The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.
- Key Consideration: Meclizine should be used with caution in patients with certain medical conditions, such as asthma, glaucoma, or enlargement of the prostate gland, due to its potential anticholinergic action 2.
From the Research
Definition and Diagnosis of Vertigo
- Vertigo is a common and diagnostic challenge faced by clinicians, characterized by short-lived episodes of vertigo in association with rapid changes in head position 3.
- The clinical assessment aims to establish the presence of true vertigo, differentiate between vertigo of central or peripheral origins, and to evaluate the need for urgent investigations and referrals 3.
- Peripheral causes of vertigo are more common, but central causes such as transient ischaemic attack or stroke should always be considered and ruled out appropriately 3.
Treatment of Benign Paroxysmal Positional Vertigo (BPPV)
- The Epley manoeuvre is a safe and effective treatment for posterior canal BPPV, with a significant reduction in vertigo symptoms and conversion of a positive Dix-Hallpike test to a negative test 4, 5, 6, 7.
- The Epley manoeuvre is more effective than vestibular rehabilitation at 1-week follow-up, with regard to patient-reported symptom relief and conversion of the Dix-Hallpike manoeuvre from positive to negative 6.
- The Epley manoeuvre is also more effective than watchful waiting in the management of posterior canal BPPV, with a clinically relevant effect in favor of the Epley manoeuvre regarding symptom relief at 1-week follow-up 7.
Comparison of Treatment Options
- The Epley manoeuvre is comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises 4.
- There is inconsistent evidence for the effectiveness of the Epley manoeuvre compared with vestibular rehabilitation at 1-month follow-up 6.
- The Epley manoeuvre should be considered in all patients with posterior canal BPPV, with a benefit in favor of the Epley manoeuvre at 1-week follow-up 7.