How should acute vertigo be treated, including management of benign paroxysmal positional vertigo, vestibular neuritis, and Menière’s disease?

Treatment of Acute Vertigo

For benign paroxysmal positional vertigo (BPPV), perform the Epley maneuver immediately upon diagnosis and avoid vestibular suppressant medications; for vestibular neuritis, use short-term vestibular suppressants (3-5 days maximum) followed by early vestibular rehabilitation; for Ménière's disease, prescribe dietary sodium restriction with diuretics and reserve vestibular suppressants only for acute attacks.

BPPV Management

The canalith repositioning procedure (Epley maneuver) is the definitive first-line treatment for BPPV, with 80% success after 1-3 treatments and 90-98% success with additional maneuvers if initial treatment fails. 1

Immediate Treatment Steps

• Execute the Dix-Hallpike maneuver bilaterally to confirm diagnosis—look for torsional upbeating nystagmus with 5-20 second latency, lasting <60 seconds, that fatigues with repeat testing 1, 2
• Perform the Epley maneuver immediately when Dix-Hallpike is positive 2, 3
• Do not prescribe postprocedural postural restrictions—these provide no additional benefit 2

What NOT to Do for BPPV

Vestibular suppressant medications (antihistamines like meclizine or benzodiazepines) should not be routinely prescribed for BPPV because they are ineffective as definitive treatment, interfere with central vestibular compensation, and increase fall risk, particularly in elderly patients. 1 The only exception is short-term use (≤3 days) for severely symptomatic patients with intractable nausea or vomiting who refuse repositioning maneuvers 1

Follow-Up Protocol

• Reassess within 1 month to confirm symptom resolution 1
• If symptoms persist, repeat the Dix-Hallpike test and perform additional repositioning maneuvers 2
• Failure to respond after appropriate treatment is a red flag requiring neuroimaging to exclude central pathology (1.1-3% of presumed BPPV cases are actually CNS lesions) 1, 2

Vestibular Neuritis Management

Begin vestibular rehabilitation exercises within the first week after acute symptoms subside—this achieves 45% complete symptom resolution at 12 months, comparable to corticosteroid therapy, with no serious adverse events reported across 21 randomized trials. 4

Acute Phase (First 3-5 Days)

• Use vestibular suppressants only for short-term symptom control during severe acute attacks 4, 5
• Meclizine 25-100 mg daily is the most commonly used antihistamine, working by suppressing the central emetic center 4
• Benzodiazepines (diazepam or clonazepam) may be added for severe vertigo and associated anxiety 4
• For severe nausea/vomiting, add prochlorperazine 5-10 mg orally or IV, maximum 3 doses per 24 hours 4

Critical Timing Considerations

Discontinue all vestibular suppressants after 3-5 days because prolonged use interferes with central vestibular compensation and increases fall risk. 4 Never use vestibular suppressants during vestibular rehabilitation—they impede the compensation process 4

Vestibular Rehabilitation Protocol

• Initiate exercises as soon as acute symptoms subside, typically within the first week 4
• Home-based exercise programs are as effective as formal supervised therapy 4
• One initial supervised instruction session followed by home practice is cost-effective 4
• Tailor protocols for patients with mobility limitations (cervical stenosis, severe arthritis, morbid obesity, spinal cord injury) 4

Common Pitfall

Do not perform canalith repositioning maneuvers (Epley) for vestibular neuritis—these are effective only for BPPV and will not help vestibular neuritis 4, 3

Ménière's Disease Management

Dietary sodium restriction combined with diuretics forms the foundation of long-term Ménière's disease management; vestibular suppressants should only be offered during acute attacks, not as continuous therapy. 4, 3, 5

Long-Term Management

• Prescribe low-salt diet (specific sodium restriction) 3, 5
• Add diuretics for maintenance therapy 3, 5
• Implement lifestyle modifications: avoid excessive caffeine, alcohol, and nicotine; manage stress; ensure adequate hydration, regular exercise, and sufficient sleep 4

Acute Attack Management

• Offer limited course of vestibular suppressants (meclizine or benzodiazepines) only during acute attacks 4
• Prochlorperazine 5-10 mg for severe nausea/vomiting, maximum 3 doses per 24 hours 4
• Discontinue suppressants as soon as the acute attack resolves 4

Evidence on Betahistine

The 2020 BEMED trial showed betahistine provided no significant benefit over placebo in reducing vertigo attack frequency over 9 months, despite earlier observational data suggesting efficacy 4, 6

Medication Safety Considerations

Vestibular Suppressant Risks

• Cause drowsiness, cognitive deficits, and driving impairment 4
• Are independent risk factors for falls, especially in elderly patients 4
• Interfere with central compensation when used long-term 1
• Decrease diagnostic sensitivity during Dix-Hallpike maneuvers through vestibular suppression 1

Special Populations

In older adults with cardiovascular disease, vestibular suppressants pose additional risks due to polypharmacy, drug-drug interactions with cardiac medications, and age-related pharmacokinetic changes affecting drug metabolism. 4 Review the medication list for deprescribing opportunities and educate patients about postural hypotension before prescribing any vestibular suppressant 4

Prochlorperazine Contraindications

• Avoid in patients with CNS depression or concurrent adrenergic blocker use 4
• Avoid in severe hypotension (can worsen hemodynamic instability) 4
• Use with caution in psychiatric history due to extrapyramidal symptom risk 4

Red Flags Requiring Urgent Neuroimaging

Any of the following demand immediate MRI brain with diffusion-weighted imaging to exclude posterior circulation stroke, cerebellar hemorrhage, or demyelinating disease: 2

• Severe postural instability with falling 2
• New-onset severe headache with vertigo 2
• Any additional neurological symptoms (dysarthria, dysmetria, dysphagia, sensory/motor deficits, diplopia, Horner's syndrome) 2
• Pure vertical nystagmus (upbeating or downbeating) without torsional component 2
• Baseline nystagmus present without provocative maneuvers 2
• Nystagmus that does not fatigue with repeated testing and is not suppressed by visual fixation 2
• Direction-changing nystagmus without changes in head position 2
• Failure to respond to appropriate peripheral vertigo treatments 2

Critical Epidemiologic Context

Approximately 25% of patients presenting with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts, yet 75-80% of stroke-related acute vestibular syndrome presents without focal neurologic deficits 2 This makes clinical red flags essential for identifying central causes that mimic peripheral vertigo.

Diagnostic Imaging Recommendations

• Do not order routine neuroimaging for diagnosed BPPV with typical Dix-Hallpike findings and no red flags 2
• CT head has <1% diagnostic yield for isolated dizziness (though it can identify acute cerebellar hemorrhage) 2
• MRI brain with diffusion-weighted imaging is mandatory when red flags are present or when clinical differentiation between peripheral and central vertigo is uncertain 2