What are the appropriate management and treatment options for a patient experiencing vertigo?

Management of Vertigo

For patients with vertigo, the first priority is to distinguish BPPV from other causes through positional testing, then treat BPPV immediately with canalith repositioning procedures (Epley maneuver for posterior canal, Barbecue Roll for horizontal canal) while avoiding vestibular suppressant medications, which are ineffective for BPPV and interfere with recovery. 1, 2

Initial Diagnostic Approach

Determine if vertigo is positional or spontaneous:

• Positional vertigo triggered by head movements suggests BPPV (most common cause, 85-95% posterior canal) and requires Dix-Hallpike testing for posterior canal or supine roll test for horizontal canal 1, 2
• Spontaneous vertigo without positional triggers suggests vestibular neuronitis, Ménière's disease, or central causes 3, 4

Red flags requiring urgent imaging and neurological evaluation:

• Severe headache, neurological deficits, or brainstem symptoms 5, 6
• Downbeating nystagmus without torsional component 7
• Direction-changing nystagmus without head position changes 7
• Lack of response to repositioning maneuvers after 2-3 attempts 2

Treatment Algorithm by Diagnosis

BPPV (Most Common - 85-95% of Cases)

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

• Perform Epley maneuver immediately - 80% success rate after 1-3 treatments, 90-98% after repeat maneuvers 1, 2
• Do NOT prescribe meclizine or other vestibular suppressants - they are ineffective as primary treatment and interfere with central compensation mechanisms 1, 2, 8
• No postprocedural restrictions needed - patients can resume normal activities immediately 1, 2

Horizontal Canal BPPV (10-15% of BPPV cases):

• Geotropic variant: Barbecue Roll (Lempert) maneuver (50-100% success) or Gufoni maneuver (93% success) 1, 2
• Apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side) 1, 2

If symptoms persist after initial treatment:

• Repeat diagnostic testing to confirm persistent BPPV 2
• Perform additional repositioning maneuvers (achieves 90-98% success) 2
• Evaluate for canal conversion (occurs in 6-7% of cases) 2
• Consider multiple canal involvement or coexisting vestibular pathology 2

Ménière's Disease

Acute attack management:

• Short-term vestibular suppressants ONLY during acute attacks: Meclizine 25-100 mg daily in divided doses for maximum 3-5 days 7, 8
• Benzodiazepines (diazepam) for severe symptoms with psychological anxiety 1

Long-term preventive therapy:

• Dietary sodium restriction to 1500-2300 mg daily 7
• Diuretics as first-line preventive therapy 7
• Limit alcohol and caffeine intake 7
• Betahistine may increase inner ear vasodilation 7

Follow-up requirements:

• Document resolution, improvement, or worsening of vertigo, tinnitus, hearing loss, and quality of life after treatment 5
• Audiometric testing to inform further therapeutic or rehabilitative options 5

Acute Vestibular Neuronitis/Labyrinthitis

Acute phase (first 24-72 hours):

• Limited course of vestibular suppressants for severe autonomic symptoms (nausea, vomiting) 1
• Meclizine 25-100 mg daily or diazepam for short-term management 7, 8

Recovery phase:

• Discontinue vestibular suppressants after 3-5 days to avoid interfering with vestibular compensation 1, 7
• Begin vestibular rehabilitation exercises 1, 3

Vestibular Rehabilitation Therapy

Indications:

• Chronic imbalance or persistent dizziness from any vestibular cause 7
• Residual dizziness, postural instability, or heightened fall risk after successful BPPV treatment 2
• Incomplete recovery from vestibular neuronitis 1

Evidence for VRT:

• Reduces BPPV recurrence rates by approximately 50% 2
• Patients treated with CRP plus VRT show significantly improved gait stability compared to CRP alone 2
• Can be self-administered or therapist-directed 7

Medication Guidelines and Critical Warnings

Vestibular suppressants (meclizine, antihistamines, benzodiazepines):

When to AVOID:

• Never use as primary treatment for BPPV - no evidence of effectiveness and interferes with recovery 1, 2, 8
• Patients with asthma, glaucoma, or prostate enlargement 7, 8

Significant adverse effects:

• Drowsiness and cognitive deficits 1, 7, 8
• Increased fall risk, especially in elderly patients 1, 7
• Anticholinergic effects 7
• Driving impairment 7, 8
• Interference with central compensation mechanisms 1, 7

Limited appropriate use:

• Short-term management (3-5 days maximum) of severe nausea/vomiting during acute non-BPPV vestibular attacks 1, 7
• Patients refusing repositioning procedures 7
• Severe autonomic symptoms in acute Ménière's attacks 1, 7

Special Populations and Modifying Factors

Assess all patients before treatment for:

• Impaired mobility or balance 5, 2
• CNS disorders (multiple sclerosis, traumatic brain injury) 5
• Lack of home support 5
• Increased fall risk - BPPV increases fall risk 12-fold, particularly in elderly patients 2

Contraindications to standard repositioning maneuvers:

• Severe cervical stenosis or radiculopathy 2
• Severe rheumatoid arthritis or ankylosing spondylitis 2
• Morbid obesity 2
• Severe kyphoscoliosis 2

Alternative approaches for patients with contraindications:

• Brandt-Daroff exercises (less effective: 24% vs 71-74% success for repositioning maneuvers) 2
• Specialized vestibular physical therapy 2

Follow-Up Protocol

Reassess within 1 month after initial treatment to:

• Document resolution or persistence of symptoms 1, 7
• Evaluate for treatment failures requiring additional interventions 2
• Counsel on fall risk and home safety assessment 5, 2
• Discuss potential recurrence (BPPV recurs in 10-18% at 1 year, 30-50% at 5 years) 2

Common Pitfalls to Avoid

• Prescribing meclizine for BPPV - this is the most common error; repositioning procedures are the only effective treatment 1, 2
• Imposing postprocedural restrictions after Epley maneuver - no benefit and may cause unnecessary complications 1, 2
• Prolonged use of vestibular suppressants - delays recovery and increases adverse effects 1, 7
• Failing to identify the affected canal before treatment leads to ineffective therapy 2
• Not reassessing treatment failures - repeat testing often reveals canal conversion or multiple canal involvement 2
• Overlooking fall risk in elderly patients - requires immediate safety counseling and home assessment 5, 2