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

Management of Vertigo

First-Line Treatment: Diagnosis-Driven Approach

For benign paroxysmal positional vertigo (BPPV), perform canalith repositioning procedures immediately—specifically the Epley maneuver for posterior canal involvement—which achieves 80% success rates after 1-3 treatments, and avoid vestibular suppressant medications as they do not address the underlying cause and may delay recovery. 1, 2

Diagnostic Algorithm by Symptom Pattern

Triggered Positional Vertigo (BPPV - 85-95% of cases):

• Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV, looking for torsional upbeating nystagmus 2
• If Dix-Hallpike is negative but BPPV suspected, perform the supine roll test for horizontal canal involvement (10-15% of cases) 2
• Immediate treatment: Epley maneuver for posterior canal BPPV with 80-98% success after repeat maneuvers if needed 1, 2
• For horizontal canal BPPV: Barbecue Roll (Lempert) maneuver for geotropic variant (50-100% success) or Gufoni maneuver (93% success) 2

Spontaneous Episodic Vertigo (Ménière's Disease):

• Dietary sodium restriction (1500-2300 mg daily) combined with diuretics as first-line preventive therapy 3
• Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) only during acute attacks, not for chronic prevention 3, 4
• Limit alcohol and caffeine intake 3
• Document resolution, improvement, or worsening of vertigo, tinnitus, hearing loss, and quality of life after treatment 5

Critical Medication Guidelines

Vestibular suppressants should NOT be routinely prescribed for BPPV as they have no evidence of effectiveness as definitive treatment and cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk, particularly in elderly patients. 1, 2, 3

Limited indications for vestibular suppressants:

• Short-term management (maximum 3-5 days) of severe nausea/vomiting during acute non-BPPV vestibular attacks 3
• Patients refusing repositioning procedures 3
• Severe autonomic symptoms in BPPV only as adjunct, not primary treatment 1

Meclizine dosing (when indicated): 25-100 mg daily in divided doses, used primarily as-needed rather than scheduled to avoid interfering with vestibular compensation 1, 4

Contraindications and warnings: Use with caution in patients with asthma, glaucoma, or prostate enlargement; avoid concurrent alcohol use; warn about driving impairment 3, 4

Post-Treatment Instructions

For BPPV patients after canalith repositioning:

• Resume normal activities immediately—postprocedural restrictions provide no benefit and may cause unnecessary complications 2, 3
• Reassess within 1 month to confirm symptom resolution 1, 3
• If symptoms persist, repeat diagnostic testing to evaluate for canal conversion (occurs in 6-7% of cases), multiple canal involvement, or coexisting vestibular pathology 2

Vestibular Rehabilitation Therapy

Offer VRT as adjunctive therapy, not as substitute for repositioning procedures, particularly for:

• Patients with residual dizziness after successful repositioning 2, 3
• Chronic imbalance or postural instability 3
• Heightened fall risk 2
• VRT reduces BPPV recurrence rates by approximately 50% 2

Special Populations and Risk Factors

Assess all patients before treatment for modifying factors:

• Impaired mobility or balance 5, 2
• CNS disorders (multiple sclerosis, traumatic brain injury—posttraumatic BPPV requires repeated treatments in up to 67% of cases) 5
• Lack of home support 5
• Increased fall risk (BPPV increases fall risk 12-fold, especially in elderly patients) 2

Patients with contraindications to standard maneuvers (severe cervical stenosis, significant vascular disease, severe rheumatoid arthritis, morbid obesity):

• Consider Brandt-Daroff exercises performed three times daily for two weeks 2
• Refer to specialized vestibular physical therapy 2

Common Pitfalls to Avoid

Do not order imaging or vestibular testing unless there are atypical neurological signs (abnormal cranial nerves, severe headache, visual disturbances, downbeating nystagmus without torsional component, direction-changing nystagmus without head position changes) 2, 3

Recognize treatment failures: If symptoms persist after 2-3 properly performed repositioning maneuvers, reassess for canal conversion, multiple canal involvement, coexisting vestibular pathology, or CNS disorders masquerading as BPPV 2

Address psychological impact: Patients with BPPV exhibit significant negative quality-of-life impact and may require counseling about fall risk at home or home safety assessment, particularly those with preexisting comorbid conditions 5

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 1, 2