What is the symptomatic treatment for peripheral vertigo (benign paroxysmal positional vertigo)?

From the Guidelines

Symptomatic treatment for peripheral vertigo should primarily focus on repositioning maneuvers, such as the Epley maneuver, rather than relying on vestibular suppressant medications. According to the most recent and highest quality study 1, clinicians should treat patients with posterior canal BPPV with a canalith repositioning procedure as the initial therapy. The use of vestibular suppressant medications, such as antihistamines and/or benzodiazepines, is not recommended for routine treatment of BPPV 1.

Key Considerations

• Repositioning maneuvers, like the Epley maneuver, have been shown to be effective in treating BPPV, with a success rate of 90% to 98% when additional repositioning maneuvers are performed 1.
• Vestibular suppressant medications may be used for short-term management of autonomic symptoms, such as nausea or vomiting, in severely symptomatic patients, but their use should be limited to the acute phase to avoid delaying central compensation 1.
• Antiemetics, such as ondansetron or promethazine, may be considered for prophylaxis in patients who have previously manifested severe nausea and/or vomiting with the Dix-Hallpike maneuvers and in whom a CRP is planned 1.
• Patients should be advised to move slowly, avoid sudden head movements, and sit or lie down when experiencing vertigo to reduce the risk of falls and improve symptoms.

Treatment Approach

• Start with repositioning maneuvers, such as the Epley maneuver, as the initial treatment for BPPV.
• Use vestibular suppressant medications only for short-term management of autonomic symptoms in severely symptomatic patients.
• Consider antiemetics for prophylaxis in patients with a history of severe nausea and/or vomiting.
• Advise patients on lifestyle modifications to reduce the risk of falls and improve symptoms.
• Once acute symptoms subside, vestibular rehabilitation exercises can help promote adaptation and should be initiated to improve long-term outcomes and prevent recurrence.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1). Recommended dosage: 25 mg to 100 mg daily, in divided doses (2.1).

Symptomatic Treatment for Peripheral Vertigo: Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.

• Key Points:
  • Indicated for vertigo associated with vestibular system diseases
  • Recommended dosage: 25 mg to 100 mg daily
• Important Considerations:
  • May cause drowsiness, use caution when driving or operating machinery
  • Potential anticholinergic action, prescribe with care to patients with asthma, glaucoma, or prostate gland enlargement 2.

From the Research

Symptomatic Treatment for Peripheral Vertigo

The approach to treating peripheral vertigo is primarily symptomatic, focusing on alleviating the symptoms rather than addressing the underlying cause. The goals of symptomatic treatment include:

• Eliminating the hallucination of motion
• Reducing accompanying neurovegetative and psychoaffective signs, such as nausea, vomiting, and anxiety
• Enhancing the process of vestibular compensation to allow the brain to find a new sensory equilibrium despite the vestibular lesion

Medications Used in Symptomatic Treatment

Various medications are used to achieve these goals, including:

• Vestibular suppressants, such as anticholinergic and antihistamine drugs, to eliminate the hallucination of motion 3
• Antidopaminergics to reduce neurovegetative and psychoaffective signs 3
• Benzodiazepines, histaminergic agents, sympathomimetics, and calcium antagonists, although their mechanisms of action are poorly understood 3
• Levo-sulpiride, methoclopramide, and triethilperazine to reduce neurovegetative symptoms in acute spontaneous vertigo 4
• Diazepam to decrease internuclear inhibition, and sulfate magnesium or piracetam to decrease vestibular damage in acute spontaneous vertigo 4

Treatment of Specific Conditions

For benign paroxysmal positional vertigo (BPPV), the most effective treatment is the canalith repositioning (CRP) maneuver 5, 6. Addition of betahistine or dimenhydrinate pharmacotherapy to CRP maneuver did not show superiority to treatment with CRP maneuvers alone 5. Vestibular rehabilitation is also helpful in treating many peripheral and central etiologies of dizziness 6.

Emerging Medical Therapies

Current and emerging medical therapies for dizziness aim to reduce vertigo, manage secondary symptoms, or address the root cause of the pathologic process. These include:

• Antihistamines, calcium channel blockers, and benzodiazepines for acute peripheral vertigo 7
• Betahistine and diuretics for Meniere disease, with intratympanic steroids and gentamicin reserved for uncontrolled symptoms 7
• 4-aminopyridine for cerebellar dizziness and oculomotor disorders 7
• Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and calcium channel blockers for vestibular migraine, persistent postural perceptual dizziness, and mal de débarquement 7