Treatment of Vertigo in Adults
The Epley maneuver (canalith repositioning procedure) is the definitive first-line treatment for BPPV—the most common cause of vertigo—with 80-93% success after 1-3 treatments, and medications are unnecessary for typical cases. 1
Initial Diagnostic Classification
Before treating vertigo, classify the pattern based on timing and triggers 2, 1:
- Brief episodic vertigo (seconds to minutes) triggered by head position changes suggests BPPV 2
- Spontaneous episodic vertigo (20 minutes to 12 hours) with hearing loss, tinnitus, or aural fullness suggests Ménière's disease 1, 3
- Acute persistent vertigo (days to weeks) suggests vestibular neuritis or labyrinthitis 2, 3
- Chronic vertigo often indicates medication side effects or vestibular migraine 1
Confirm true vertigo by asking if the patient feels spinning or rotation, as vague "dizziness" or lightheadedness suggests non-vestibular causes requiring different management 1.
Essential Physical Examination
Perform the Dix-Hallpike maneuver for all patients with suspected BPPV 1. A positive test shows torsional, upbeating nystagmus with 5-20 second latency that resolves within 60 seconds 2, 3.
Check for red flags indicating central causes requiring urgent MRI 1:
- Downbeating nystagmus without torsional component 1
- Direction-changing nystagmus without head position changes 1
- Severe postural instability or focal neurologic deficits 1
- Age >50 with vascular risk factors 1
- Neck stiffness with vertigo 3
Treatment by Diagnosis
BPPV (Most Common)
Perform the Epley maneuver immediately—this is vastly superior to medications with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers 2, 1, 3. No imaging or medication is needed for typical cases 2.
If no improvement after repositioning maneuvers or atypical presentation, obtain MRI brain to exclude central causes, as 3% of BPPV treatment failures have CNS disorders masquerading as BPPV 1.
Ménière's Disease
First-line preventive therapy combines dietary sodium restriction with diuretics 1. Consider betahistine to increase inner ear vasodilation 1. Diagnosis requires episodic vertigo lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, or aural fullness 1, 3.
Vestibular Neuritis/Labyrinthitis
Characterized by acute persistent vertigo lasting days with severe nausea/vomiting, no hearing loss, and horizontal nystagmus that lessens with visual fixation 3. Initial treatment includes vestibular suppressant medication followed by vestibular rehabilitation exercises 4.
Vestibular Migraine
Accounts for 14% of all vertigo cases but is extremely under-recognized 2. Treatment includes migraine prophylaxis and lifestyle modifications 2. Motion intolerance and light sensitivities help differentiate from Ménière's 2.
Role of Medications
Meclizine is FDA-approved for vertigo associated with vestibular system diseases 5. Recommended dosage is 25-100 mg daily in divided doses 5. However, medications are unnecessary for typical BPPV cases where the Epley maneuver is definitive treatment 1.
Common adverse reactions include drowsiness, dry mouth, headache, and fatigue 5. Use caution when driving or operating machinery 5. Prescribe with care in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 5.
Vestibular Rehabilitation
Vestibular rehabilitation is indicated for 1:
- Persistent dizziness from any vestibular cause
- Chronic imbalance or incomplete recovery
- Elderly patients or those with heightened fall risk 2
This significantly improves gait stability compared to medication alone 2.
Critical Pitfalls to Avoid
Do not assume a normal neurologic exam excludes stroke—75-80% of posterior circulation strokes causing acute vestibular syndrome have no focal neurologic deficits initially 3. High vascular risk patients require MRI brain without contrast even with normal examination 2.
Do not order CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts with only 20-40% sensitivity, while MRI has 4% diagnostic yield versus <1% for CT 3.
Do not attribute symptoms to anxiety prematurely—anxiety is often a secondary response to acute vestibular dysfunction, not the primary cause 3.
Do not perform Dix-Hallpike when neck stiffness is present, as this suggests possible central pathology requiring urgent evaluation 3.
Follow-Up
Reassess patients within 1 month after initial treatment to document resolution or persistence 1. Counsel on fall risk (dizziness increases fall risk 12-fold in elderly patients), BPPV recurrence rates, and importance of reporting atypical symptoms 2, 1.