What are the treatment options for vertigo?

Treatment of Vertigo

The treatment of vertigo depends critically on the underlying cause: canalith repositioning maneuvers (Epley or Semont) are first-line for BPPV with 80% success rates, while vestibular suppressant medications like meclizine should only be used short-term (3-5 days maximum) for severe acute symptoms and are NOT appropriate as primary treatment for most vertigo conditions. 1

Diagnosis-Specific Treatment Algorithm

For BPPV (Benign Paroxysmal Positional Vertigo)

Primary Treatment:

• Perform canalith repositioning maneuvers (Epley or Semont) as first-line therapy, achieving 78.6%-93.3% improvement compared to only 30.8% with medication alone 1
• Success rates reach approximately 80% with only 1-3 treatments 1
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends AGAINST routine use of vestibular suppressants for BPPV 1, 2

Limited Medication Role:

• Meclizine may ONLY be considered for severe nausea/vomiting during repositioning procedures, NOT as primary treatment 1
• Prochlorperazine 5-10 mg may be used for severe autonomic symptoms (maximum three doses per 24 hours) 3
• Medications can actually interfere with recovery and should be avoided as definitive therapy 1

For Ménière's Disease

Acute Attack Management:

• Use vestibular suppressants for SHORT-TERM relief only during acute attacks 4
• Meclizine 25-100 mg daily in divided doses, prescribed as-needed rather than scheduled 1, 5
• Limit use to 3-5 days maximum to avoid delaying vestibular compensation 3

Maintenance Therapy:

• Dietary sodium restriction to 1500-2300 mg daily 4, 3
• Diuretics may be offered for maintenance therapy to reduce attack frequency 4
• Betahistine may be considered, though the BEMED trial showed no significant benefit over placebo 1

Advanced Options for Refractory Cases:

• Intratympanic steroids for active disease not responsive to noninvasive treatment 4
• Consider intratympanic gentamicin or surgical options for severe, intractable cases 4

For Acute Vestibular Neuritis/Labyrinthitis

Immediate Management (First 3-5 Days):

• Meclizine 25-100 mg daily in divided doses, as-needed only 1, 5
• Prochlorperazine 5-10 mg for severe nausea/vomiting (maximum three doses per 24 hours) 3
• Short-term benzodiazepines (diazepam 10 mg) may be considered for severe vertigo with anxiety, though fall risk is significant in elderly 3
• Consider oral corticosteroids if inflammatory process is suspected 3

Critical Transition:

• STOP vestibular suppressants after 3-5 days 3
• Begin Vestibular Rehabilitation Therapy (VRT) as soon as acute symptoms are manageable (typically within 3-7 days) 3
• VRT is more effective than prolonged medication use for lasting symptom resolution 3

Medication Dosing and Safety

Meclizine (FDA-Approved)

• Dosing: 25-100 mg daily in divided doses 5
• Administration: Swallow tablets whole, use as-needed rather than scheduled 1, 5
• Contraindications: Hypersensitivity to meclizine or inactive ingredients 5
• Warnings: May cause drowsiness affecting driving ability; use with caution in asthma, glaucoma, or prostate enlargement 5

Critical Safety Warnings for All Vestibular Suppressants

Fall Risk:

• Vestibular suppressants are an independent risk factor for falls, particularly in elderly patients 1, 3
• Anticholinergic side effects include drowsiness, cognitive deficits, dry mouth, blurred vision, and urinary retention 1

Interference with Recovery:

• Long-term use (>3-5 days) interferes with central vestibular compensation, potentially prolonging overall recovery time 3
• Medications can decrease diagnostic sensitivity during Dix-Hallpike maneuvers 2

Vestibular Rehabilitation Therapy

Indications:

• Chronic imbalance following acute vestibular events 4
• Persistent symptoms after initial treatment 3
• Should NOT be used for acute vertigo attacks in Ménière's disease 4

Timing:

• Begin within 3-7 days of acute symptom onset 3
• More effective than prolonged medication use for long-term recovery 3

Lifestyle Modifications (All Vertigo Types)

• Limit sodium intake to 1500-2300 mg daily, especially for Ménière's disease 3
• Avoid excessive caffeine, alcohol, and nicotine 1, 3
• Maintain adequate hydration and regular sleep patterns 1, 3
• Implement stress management techniques 1, 3
• Regular exercise when tolerated 1

Follow-Up Protocol

• Reassess within 1 month to document symptom resolution or persistence 1, 3
• Discontinue vestibular suppressants as soon as possible 1
• If symptoms persist beyond 4-6 weeks despite appropriate treatment, consider alternative diagnoses (vestibular migraine, BPPV variants, bilateral vestibular hypofunction) 3

Common Pitfalls to Avoid

Do NOT:

• Use meclizine or other vestibular suppressants as primary treatment for BPPV 1, 2
• Prescribe vestibular suppressants on a scheduled basis—use as-needed only 1
• Continue vestibular suppressants beyond 3-5 days 3
• Use vestibular rehabilitation during acute Ménière's attacks 4
• Prescribe positive pressure therapy (Meniett device) for Ménière's disease—it is ineffective 4

Do:

• Identify the specific cause of vertigo before initiating treatment 1
• Prioritize physical therapy maneuvers for BPPV over medications 1
• Transition to vestibular rehabilitation as soon as acute symptoms allow 3
• Counsel patients about expected symptom duration and fall risk 1, 3