How should benign paroxysmal positional vertigo, vestibular neuritis, and Meniere’s disease be treated?

Treatment for Vertigo

Benign Paroxysmal Positional Vertigo (BPPV)

Perform the Epley canalith repositioning maneuver immediately upon diagnosis—this is first-line treatment with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers if initial treatment fails. 1, 2

Diagnostic Confirmation

• Execute the Dix-Hallpike maneuver bilaterally to confirm posterior canal BPPV (85-95% of cases), looking for torsional upbeating nystagmus with 5-20 second latency that resolves within 60 seconds 1
• If Dix-Hallpike is negative, perform the supine roll test to detect lateral canal BPPV (5-15% of cases) 1

Treatment Protocol

• Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV—these medications do not correct the mechanical pathology and delay central compensation 1, 2
• No post-procedural postural restrictions are necessary 2
• Reassess within 1 month to document resolution or persistence 1, 2
• If symptoms persist after 2-3 repositioning attempts, refer for vestibular rehabilitation therapy 2

Patient Counseling

• Counsel about recurrence risk and fall prevention, particularly in elderly patients where BPPV increases fall risk 12-fold 2
• Educate on home-based repositioning maneuvers for recurrent episodes 1

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Vestibular Neuritis

Vestibular suppressants should be limited to the acute phase only (first 2-3 days), followed by early vestibular rehabilitation to promote central compensation. 2, 3

Acute Phase Management (First 72 Hours)

• Antiemetics for severe nausea: metoclopramide 10 mg IV or prochlorperazine 10 mg IV 2
• Short-term vestibular suppressants only if severe distress: meclizine 25 mg every 6 hours or diazepam 2-5 mg 3, 4
• Consider oral corticosteroids for acute attacks (evidence from Ménière's management principles) 2

Subacute Phase (After 72 Hours)

• Discontinue vestibular suppressants to avoid delaying central compensation 2, 3
• Initiate vestibular rehabilitation therapy immediately—this significantly improves gait stability compared to medication alone 2
• Vestibular rehabilitation includes habituation exercises, gaze stabilization, balance retraining, and fall prevention 2

Expected Course

• Severe rotational vertigo lasts 12-36 hours, followed by 4-5 days of decreasing disequilibrium 2
• Most patients recover fully with appropriate vestibular rehabilitation 4

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Ménière's Disease

Initiate dietary sodium restriction and diuretics as first-line therapy; escalate to intratympanic gentamicin or surgical intervention only for refractory cases with severe progressive hearing loss. 2, 5

Diagnostic Criteria

• At least two spontaneous vertigo episodes lasting 20 minutes to 12 hours 2, 5
• Fluctuating low-to-mid frequency sensorineural hearing loss documented on audiometry 2, 5
• Fluctuating tinnitus and aural fullness in the affected ear 2, 5

First-Line Medical Management

• Dietary sodium restriction (1,500-2,000 mg/day) 2, 5
• Diuretics for persistent symptoms (though evidence is limited) 2
• Betahistine (commonly used in Europe for symptom control) 2

Acute Attack Management

• Oral corticosteroids for acute vertigo episodes 2
• Antiemetics (metoclopramide or prochlorperazine) for nausea 2
• Short-term vestibular suppressants only during acute attacks 2

Escalation for Refractory Disease

• Intratympanic gentamicin for refractory vertigo when medical therapy fails 2, 5
• Endolymphatic sac decompression surgery reserved for patients who do not respond to conservative and medical measures 2
• Destructive interventions should be reserved for those with severe progressive hearing loss or lack of usable hearing 2

Monitoring

• Comprehensive audiometry to document fluctuating hearing pattern 2, 5
• Electrocochleography may reveal elevated summating-potential/action-potential ratio but is optional 2

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Vestibular Migraine

Treat with migraine prophylaxis and lifestyle modifications; for acute attacks, use naproxen 500-550 mg plus sumatriptan 50-100 mg when initiated promptly after headache onset. 2, 5

Diagnostic Criteria

• Episodic vestibular symptoms lasting 5 minutes to 72 hours 2
• Current or past history of migraine by International Headache Society criteria 2
• At least two migraine symptoms (headache, photophobia, phonophobia, visual aura) during at least two vertiginous episodes 2, 5
• Stable or absent hearing loss (distinguishes from Ménière's disease) 2, 6

Acute Attack Management

• Naproxen 500-550 mg orally PLUS sumatriptan 50-100 mg orally when initiated promptly 2
• Avoid NSAID-triptan combination in pregnancy or breastfeeding 2
• Educate about medication-overuse headache risk (NSAIDs ≥15 days/month or triptans ≥10 days/month) 2

Prophylactic Management

• Migraine prophylaxis medications (specific agents not detailed in guidelines, but standard migraine prophylaxis applies) 2, 5
• Lifestyle modifications including trigger avoidance 2
• Dietary modifications 6

Important Distinction

• Vestibular migraine accounts for 14% of all vertigo cases but is markedly under-recognized, especially in younger adults 2, 5
• Motion intolerance and light sensitivities help differentiate from Ménière's disease 2

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Critical Red Flags Requiring Urgent Neuroimaging

Obtain urgent MRI brain without contrast immediately if any of the following are present, as 25% of acute vestibular syndrome cases are posterior circulation stroke (rising to 75% in high vascular risk cohorts): 2, 6

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke) 2
• Focal neurological deficits (dysarthria, limb weakness, sensory loss, diplopia, Horner's syndrome) 2, 6
• Severe postural instability with falling 2, 6
• New severe headache accompanying vertigo 2
• Pure vertical nystagmus (upbeating or downbeating) without torsional component 2, 6
• Direction-changing nystagmus without head position changes 2, 6
• Baseline nystagmus present without provocative maneuvers 2, 6
• Normal head-impulse test (suggests central cause) 2
• Skew deviation on alternate cover testing 2
• Sudden unilateral hearing loss 2, 5
• Failure to respond to appropriate vestibular treatments 2, 6

Imaging Pitfalls to Avoid

• Do NOT use CT head for suspected stroke—it has <1% diagnostic yield for posterior circulation infarcts and misses most cases 2
• MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT 2
• 75-80% of posterior circulation stroke patients have NO focal neurologic deficits on initial exam 2

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When Imaging Is NOT Indicated

• Typical BPPV with positive Dix-Hallpike test and no red flags 2
• Acute persistent vertigo with normal neurologic exam, peripheral HINTS pattern by trained examiner, and low vascular risk 2
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits 2