What is vertigo and how is it treated?

Understanding and Treating Vertigo

Vertigo is a false sensation of spinning or rotational movement that requires cause-specific treatment, with benign paroxysmal positional vertigo (BPPV) treated primarily through canalith repositioning maneuvers rather than medications, while other vestibular disorders may require short-term vestibular suppressants only for acute symptom relief. 1, 2

What Vertigo Is

Vertigo represents an illusory sensation of motion, typically rotational, where patients experience either self-motion or the perception that their surroundings are spinning. 1 This differs fundamentally from lightheadedness or presyncope, which the Barany Society defines as disturbed spatial orientation without false motion sensation. 1 Clinicians must confirm patients are describing true spinning rather than vague "dizziness" to make accurate diagnoses. 1

Key Distinguishing Features

• True vertigo involves a distinct spinning sensation, often described as room rotation 1
• Duration matters: BPPV episodes last seconds to one minute, Ménière's disease attacks last hours, while vestibular neuritis causes prolonged vertigo exceeding 24 hours 1
• Triggers identify the cause: Position changes suggest BPPV, spontaneous attacks suggest Ménière's disease or vestibular neuritis 1

Common Causes of Vertigo

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is the most common cause of vertigo, characterized by brief episodes (under 60 seconds) triggered by specific head position changes. 1 Episodes occur with rolling over in bed, looking upward, or bending forward. 1 The condition results from displaced calcium carbonate crystals (otoconia) in the semicircular canals. 1

Most BPPV cases occur without identifiable cause, though associations exist with trauma, migraine, diabetes, osteoporosis, and prolonged bed rest. 1

Ménière's Disease

This condition presents with spontaneous vertigo attacks lasting hours, accompanied by fluctuating hearing loss, tinnitus, and aural fullness. 1 Unlike BPPV, attacks are not position-triggered and involve distinct otologic symptoms. 1

Vestibular Neuritis/Labyrinthitis

These conditions cause acute, prolonged vertigo lasting 12-36 hours with severe nausea and vomiting. 1 Vestibular neuritis occurs without hearing loss, while labyrinthitis includes profound hearing loss. 1

Diagnostic Approach

For Suspected BPPV

Diagnosis requires the Dix-Hallpike maneuver, which moves patients from upright to supine position with head turned 45 degrees and neck extended 20 degrees. 1

The diagnostic criteria include:

• History: Repeated vertigo episodes with position changes 1
• Physical examination findings: 1
  • Vertigo with nystagmus provoked by Dix-Hallpike test
  • Latency period of 5-20 seconds (up to 60 seconds) between maneuver completion and symptom onset
  • Symptoms increase then resolve within 60 seconds from nystagmus onset

Imaging and laboratory testing cannot confirm BPPV—diagnosis is purely clinical. 1

Distinguishing Central from Peripheral Causes

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) optimizes differentiation between dangerous central causes and benign peripheral vertigo. 3 Central causes warrant immediate neuroimaging, while peripheral causes can be managed in primary care. 4, 5

Treatment Strategies

BPPV Treatment

Canalith repositioning maneuvers (Epley or Semont) are first-line treatment for BPPV, achieving 80% success rates with only 1-3 treatments, compared to 30.8% improvement with medication alone. 1, 2

Managing the Repositioning Procedure

Before performing the maneuver:

• Counsel patients they will experience intense vertigo with possible nausea lasting under 60 seconds 2
• Identify high-risk patients with motion sickness history who may need prophylactic antiemetics 2
• Position patients so their head can hang slightly off the bed edge in supine position 1

During the procedure:

• Maintain each position for 20-30 seconds, allowing symptoms to subside before advancing 2
• Move slowly between positions if severe nausea develops 2
• Provide continuous support to minimize excessive movement 2

When Medications Are Appropriate for BPPV

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine medication treatment for BPPV. 2 Medications do not address the underlying mechanical problem of displaced crystals. 1

Limited exceptions include:

• Prophylaxis before repositioning in patients with previous severe nausea during maneuvers 2
• Acute nausea/vomiting management during or immediately after repositioning 2
• Temporary relief while arranging definitive repositioning treatment 2

Meclizine specifically should not be prescribed as primary BPPV treatment, as studies demonstrate substantially inferior outcomes compared to repositioning maneuvers (30.8% vs 78.6-93.3% improvement). 2

Ménière's Disease Treatment

Dietary salt restriction combined with diuretics forms the foundation of Ménière's disease management, with vestibular suppressants reserved only for acute attacks, not continuous therapy. 2, 6

Treatment approach:

• Limit sodium intake to reduce endolymphatic hydrops 2, 6
• Prescribe diuretics for attack prevention 2
• Use vestibular suppressants (meclizine 25-100 mg or benzodiazepines) only during acute attacks 2, 6
• Avoid betahistine, which showed no benefit over placebo in the 2020 BEMED trial 6

Vestibular Neuritis/Labyrinthitis Treatment

Initial management includes short-term vestibular suppressants for severe symptoms, followed by early vestibular rehabilitation exercises to promote central compensation. 4, 7

Medication Guidelines

Meclizine (Antihistamine)

FDA-approved dosing: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases. 8

Use as-needed (PRN) rather than scheduled dosing to avoid interfering with vestibular compensation. 2, 6 The medication works by suppressing the central emetic center. 6

Important Contraindications and Warnings

Meclizine is contraindicated in patients with hypersensitivity and should be prescribed with extreme caution in elderly patients due to significant fall risk. 8, 2

Specific concerns:

• Anticholinergic effects: Drowsiness, cognitive deficits, dry mouth, blurred vision, urinary retention 2, 8
• Fall risk: Particularly dangerous in elderly patients 2, 6
• Driving impairment: Patients must avoid operating vehicles or machinery 2, 8
• Drug interactions: Increased CNS depression with alcohol or other CNS depressants 8
• CYP2D6 interactions: Potential for drug-drug interactions with CYP2D6 inhibitors 8

The American Academy of Otolaryngology-Head and Neck Surgery recommends against routine meclizine prescription for elderly patients with dizziness. 2

Prochlorperazine (Antiemetic)

Prochlorperazine should only be used for short-term management of severe nausea/vomiting associated with vertigo, not as primary vertigo treatment. 2, 9

Dosing: 5-10 mg orally or intravenously, maximum three doses per 24 hours 6

Clinical practice guidelines explicitly recommend against routine prochlorperazine use for vertigo treatment, as it addresses nausea but not the underlying vestibular disorder. 9

Limited appropriate uses:

• Severe nausea/vomiting during acute vestibular episodes 2, 9
• Temporary symptom relief before definitive treatment 9
• Patients refusing other treatments as a last resort 9

Adverse effects include drowsiness, cognitive deficits, increased fall risk in elderly patients, and potential interference with diagnostic testing. 9

Benzodiazepines

Short-term benzodiazepine use may help manage severe vertigo symptoms and psychological anxiety secondary to vertigo. 2, 6 However, long-term use interferes with central vestibular compensation. 6

Critical Pitfalls to Avoid

Medication Overuse

Prolonged vestibular suppressant use prevents central compensation and perpetuates symptoms rather than resolving them. 6 Medications should be discontinued as soon as acute symptoms improve. 2, 6

Misdiagnosing BPPV

Up to one-third of patients with atypical histories still demonstrate positional nystagmus on Dix-Hallpike testing, confirming BPPV. 1 Always perform bedside testing rather than relying solely on history. 1

Elderly Patient Management

Seniors with BPPV face higher fall and injury risk and should seek professional help quickly for repositioning treatment rather than observation or medication. 1, 2 Vestibular suppressants carry particularly high risks in this population due to anticholinergic burden and fall risk. 2

Missing Central Causes

Loss of consciousness never occurs with peripheral vertigo—this finding mandates immediate evaluation for central causes. 1 Similarly, neurologic symptoms (dysphagia, dysphonia, facial numbness) suggest central pathology requiring urgent imaging. 1, 5

Follow-Up and Monitoring

Reassess all vertigo patients within 1 month to document symptom resolution or persistence. 2, 6 This visit should:

• Confirm treatment success or identify need for alternative approaches 2
• Discontinue vestibular suppressants if still prescribed 2
• Transition to vestibular rehabilitation when appropriate for long-term recovery 2, 6

For BPPV specifically, resolution is confirmed when position changes no longer provoke symptoms and repeat Dix-Hallpike testing is negative. 1

Lifestyle Modifications

All vertigo patients benefit from specific lifestyle changes regardless of underlying cause. 2, 6

Recommended modifications:

• Limit sodium intake (especially critical for Ménière's disease) 2, 6
• Avoid excessive caffeine, alcohol, and nicotine 2, 6
• Maintain adequate hydration 2
• Engage in regular exercise 2
• Ensure sufficient sleep 2
• Manage stress appropriately 2, 6