What are the treatment options for a patient experiencing vertigo?

Treatment of Vertigo

The treatment of vertigo depends entirely on the underlying cause: for BPPV (the most common cause), perform the Epley maneuver immediately without any medications; for acute vestibular neuronitis or Ménière's disease attacks, use short-term vestibular suppressants only during the acute phase; and avoid routine use of medications for BPPV as they are ineffective and potentially harmful. 1, 2, 3

Diagnostic Algorithm: Identify the Cause First

Before treating vertigo, you must determine which type you're dealing with:

• Perform the Dix-Hallpike test to diagnose posterior canal BPPV (accounts for 85-95% of BPPV cases), looking for torsional upbeating nystagmus 2
• If Dix-Hallpike is negative but BPPV suspected, perform the supine roll test to assess for lateral semicircular canal BPPV (10-15% of cases) 2
• Distinguish peripheral from central causes through history and physical examination, as central causes require imaging and different management 4, 5

Treatment by Diagnosis

Benign Paroxysmal Positional Vertigo (BPPV)

Primary Treatment:

• Perform the Epley maneuver immediately as first-line definitive treatment with 80-98% success rates after 1-3 treatments 1, 2, 3
• The Epley maneuver involves: patient sitting upright with head turned 45° toward 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
• For horizontal canal BPPV (geotropic variant), use the Barbecue Roll (Lempert) maneuver with 50-100% success rates 2
• For horizontal canal BPPV (apogeotropic variant), use the Modified Gufoni maneuver 2

Critical Post-Treatment Instructions:

• Patients can resume normal activities immediately - do NOT impose postprocedural restrictions as they provide no benefit and may cause unnecessary complications 2, 3
• Reassess within 1 month to confirm symptom resolution 1, 2

Medication Management for BPPV:

• DO NOT prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) as primary treatment - they have no evidence of effectiveness for BPPV and cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk 1, 2, 3
• Vestibular suppressants may only be considered for short-term management (maximum 3-5 days) of severe nausea/vomiting in patients refusing repositioning or requiring prophylaxis immediately before/after the maneuver 3

Acute Vestibular Neuronitis/Labyrinthitis

• Use vestibular suppressants only during the acute attack (not as continuous therapy) for symptom control 1
• Meclizine 25-50 mg as initial dose for severe symptoms 1
• Add prochlorperazine if severe nausea/vomiting occurs 1
• Transition to vestibular rehabilitation exercises after acute phase for long-term recovery 1, 3

Ménière's Disease

Preventive Therapy:

• Dietary sodium restriction (1500-2300 mg daily) combined with diuretics as first-line preventive therapy 3
• Limit alcohol and caffeine intake 3
• Betahistine may be considered to increase inner ear vasodilation 3

Acute Attack Management:

• Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) only during acute vertigo attacks 3
• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after treatment 6

Vestibular Suppressant Medications: Critical Safety Information

FDA-Approved Dosing (Meclizine):

• Recommended dosage: 25 mg to 100 mg daily, in divided doses for vertigo associated with vestibular system diseases 7
• Contraindicated in patients with hypersensitivity to meclizine or inactive ingredients 7

Warnings and Precautions:

• May cause drowsiness - use caution when driving or operating machinery 7
• Anticholinergic effects - prescribe with care in patients with asthma, glaucoma, or prostate enlargement 3, 7
• Independent risk factor for falls, particularly in elderly patients 1
• Significant side effects include drowsiness, cognitive deficits, and impaired driving ability 1
• Long-term use hinders central vestibular compensation 1
• Coadministration with other CNS depressants (including alcohol) may result in increased CNS depression 7

Vestibular Rehabilitation Therapy

• Offer VRT as adjunctive therapy (not as substitute for repositioning maneuvers) particularly for patients with residual dizziness, postural instability, or heightened fall risk after successful treatment 2, 3
• VRT reduces recurrence rates by approximately 50% in BPPV patients 2
• Indicated for persistent dizziness from any vestibular cause, chronic imbalance, or incomplete recovery 3

Treatment Failures: When to Reassess

If symptoms persist after initial treatment:

• Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV 2
• Perform additional repositioning maneuvers - repeat CRP achieves 90-98% success rates 2
• Check for canal conversion (occurs in 6-7% of cases) where posterior canal may convert to lateral canal or vice versa 2
• Evaluate for multiple canal involvement or bilateral BPPV 2
• Consider coexisting vestibular pathology if symptoms are provoked by general head movements or occur spontaneously 2
• Rule out CNS disorders masquerading as BPPV, especially if atypical features present 2

Special Populations and Contraindications

Assess all patients before treatment for:

• Severe cervical stenosis or radiculopathy - consider Brandt-Daroff exercises or specialized vestibular physical therapy instead 2
• Severe rheumatoid arthritis or ankylosing spondylitis 2
• Morbid obesity, Down syndrome, Paget's disease, retinal detachment, or spinal cord injuries - may require modified approaches 2
• Elderly patients - warrant particular attention due to 12-fold increased fall risk with BPPV 2

Common Pitfalls to Avoid

• DO NOT use meclizine or antihistamines for BPPV - they are ineffective and delay compensation 1
• DO NOT use vestibular suppressants on a scheduled/continuous basis - use only as needed for acute symptoms 1
• AVOID routine CT/MRI brain scans for BPPV without neurologic red flags 1
• AVOID long-term benzodiazepine use due to risk of dependence 1
• DO NOT impose postprocedural restrictions after canalith repositioning procedures 2

Self-Treatment Options

• Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment, with 64% improvement rate (compared to 23% for Brandt-Daroff exercises) 2, 3