Treatment of Chronic Vertigo
Vestibular rehabilitation therapy (VRT) is the cornerstone treatment for chronic vertigo and should be offered to all patients with chronic imbalance, regardless of underlying etiology. 1
Initial Diagnostic Clarification
Before initiating treatment, distinguish the specific cause of chronic vertigo, as management differs substantially:
- Chronic imbalance from Ménière's disease (interictal instability or post-ablative therapy): VRT is strongly recommended based on systematic reviews showing improved symptom control, safety, reduced fall risk, improved confidence, and enhanced quality of life 1
- Bilateral vestibular hypofunction: VRT has a strong recommendation based on 4 level 1 RCTs demonstrating benefit via objective and subjective measures 1
- Vestibular migraine with chronic symptoms: Implement dietary modifications (salt restriction, avoiding excessive caffeine/alcohol/nicotine), adequate hydration, regular sleep patterns, stress management, and regular exercise immediately 2, 3
- Post-treatment imbalance: Following ablative procedures (intratympanic gentamicin or labyrinthectomy), VRT improves motion sensitivity and subjective symptoms based on level 1 RCT evidence 1
Vestibular Rehabilitation Protocol
VRT should focus on habituation, adaptation, and compensation exercises for vestibular deficits: 2, 3
- Progressive exercises performed until symptoms fatigue (Cawthorne-Cooksey exercises) 3
- Home-based therapy is equally effective as clinician-supervised therapy, though initial instruction is important 3
- VRT is particularly beneficial for elderly patients and may decrease symptom recurrence 3
- Benefits develop over weeks of consistent practice, not immediately 4
Pharmacological Management for Specific Etiologies
Vestibular Migraine (≥2 symptomatic days/month)
First-line preventive medications: 2, 3
- Beta blockers (propranolol, metoprolol, atenolol, or bisoprolol) 2
- Topiramate 2
- Assess efficacy after 2-3 months at therapeutic dose before declaring treatment failure 2, 3
Second-line options if first-line fails: 2
Third-line for refractory cases: 2, 3
- CGRP monoclonal antibodies (erenumab, fremanezumab, or eptinezumab) - assess efficacy after 3-6 months 3
- OnabotulinumtoxinA for chronic migraine with vestibular symptoms - assess efficacy after 6-9 months 3
Ménière's Disease with Chronic Symptoms
Acute Symptom Management (Short-term Only)
Meclizine 25-100 mg daily in divided doses is FDA-approved for vertigo associated with vestibular system diseases: 5
- Must be swallowed whole 5
- Causes drowsiness; patients should avoid driving and alcohol 5
- Use with caution in asthma, glaucoma, or prostate enlargement 5
Critical Contraindications and Pitfalls
Do NOT use VRT during acute vertigo attacks - it may worsen symptoms and is contraindicated based on RCT evidence 1, 4
Avoid prolonged vestibular suppressant use: 3, 4
- Impairs central compensation and delays recovery 3, 4
- Vestibular suppressants are indicated only for acute attacks, not long-term management 3
- Avoid prolonged benzodiazepine use due to drug dependence risk 3
- Oral ergot alkaloids - questionable efficacy with considerable adverse effects 2, 3
- Opioids - questionable efficacy with considerable adverse effects 2, 3
- Barbiturates - questionable efficacy with considerable adverse effects 2, 3
Do not abandon preventive treatment prematurely - efficacy takes weeks to months to establish 2, 3
Reassessment and Treatment Failure
Reassess within 1 month to confirm symptom resolution or identify treatment failure: 1, 2, 3
If symptoms persist:
- Determine if vertigo is provoked by positional changes (suggests persistent BPPV requiring canalith repositioning) 1, 3
- Screen for coexisting vestibular conditions 1, 3
- Rule out central causes if symptoms persist or worsen, particularly with atypical features 1, 3
- Assess for canal conversion (occurs in ~6% of cases) 1, 3
Comorbidity Management
Screen for and treat concurrently: 2, 3
These conditions worsen vertigo and require concurrent treatment for optimal outcomes 2, 3