From the Guidelines
Outpatient management of vertigo should prioritize identifying the specific cause, with benign paroxysmal positional vertigo (BPPV) being the most common, and treating it with canalith repositioning maneuvers such as the Epley maneuver, as recommended by the strongest and most recent evidence 1.
Key Considerations
- The diagnosis of BPPV should be made based on the Dix-Hallpike maneuver, which is a strong recommendation by the guidelines 1.
- Vestibular suppressants like meclizine, dimenhydrinate, or diazepam can be used short-term to manage acute symptoms, but their use should be limited due to the potential to delay central compensation if used for extended periods.
- Vestibular rehabilitation therapy is beneficial for many vertigo types, particularly for vestibular neuritis or persistent symptoms, and can be offered as an option for the initial treatment of BPPV 1.
- Patient education is crucial, and clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up, as emphasized in the guidelines 1.
Management Approach
- Canalith repositioning maneuvers, such as the Epley maneuver, should be performed in the office and taught to patients for home use for BPPV specifically, as recommended by the guidelines 1.
- For Ménière's disease, a low-salt diet, diuretics, and avoiding caffeine and alcohol are recommended.
- Antiemetics such as ondansetron can help control associated nausea.
- Patients should be advised to move slowly, avoid sudden head movements, and maintain hydration.
Referral and Follow-up
- Patients should be referred to specialists if symptoms persist beyond 2-3 weeks, worsen, or are accompanied by neurological symptoms like hearing loss, severe headache, or visual disturbances.
- Clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution, as recommended by the guidelines 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 Outpatient Management: Meclizine hydrochloride tablets can be used for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.
- Key Considerations:
From the Research
Vertigo Outpatient Management
- The Epley maneuver is considered a primary treatment for Benign Paroxysmal Positional Vertigo (BPPV) 3, 4, 5, 6.
- Anti-vertigo medications such as betahistine and dimenhydrinate can be effective in reducing residual symptoms of BPPV when used in conjunction with the Epley maneuver 3.
- The Epley maneuver has been shown to be more effective than vestibular rehabilitation in treating posterior canal BPPV at 1-week follow-up, with significant improvements in patient-reported symptom relief and conversion of the Dix-Hallpike test from positive to negative 4, 6.
- However, the evidence for the effectiveness of the Epley maneuver compared to vestibular rehabilitation at 1-month follow-up is inconsistent 4.
- The Epley maneuver is a safe and effective treatment for posterior canal BPPV, with a high recurrence rate of 36% 5.
- Other treatment options, such as the Semont and Gans maneuvers, have been shown to be comparable to the Epley maneuver in terms of effectiveness, while Brandt-Daroff exercises are less effective 5.
- Watchful waiting is not a recommended management option for patients with posterior canal BPPV, as the Epley maneuver has been shown to provide significant symptom relief at 1-week follow-up 6.
- A systematic assessment of the dizzy patient using the Triage-Timing-Trigger-Test (Triage + TiTraTe) method can help accurately diagnose the underlying cause of peripheral vertigo and rule out life-threatening causes 7.