Pharmacological therapy
Benign Paroxysmal Positional Vertigo (BPPV)
Medications are not routinely given in benign paroxysmal positional vertigo other than in patients with severe vegetative symptoms such as nausea or vomiting.
Meniere’s Disease
Vertigo_Management 1Antiemetic medications (eg Metoclopramide, Prochlorperazine, Promethazine) may be given for nausea and vomiting control. Benzodiazepines may be used to suppress vertigo and vertigo-associated nausea. Diuretics (a combination of Acetazolamide and Hydrochlorothiazide) help lower endolymphatic pressure. Betahistine and labyrinth ablation therapies with intratympanic Gentamicin also aid in lowering endolymphatic pressure. Intratympanic glucocorticoids showed some benefit in patients with intractable unilateral Meniere’s disease. Vestibular blocking or suppressant agents (eg Betahistine, Diazepam, Dimenhydrinate, Glycopyrrolate, Lorazepam, Meclizine) may be given to reduce the spinning sensation.
Antihistamines with calcium channel blocking activity (eg Cinnarizine) may be effective in patients with “vestibular Meniere’s” due to the high prevalence of migraine in these patients. A recent study supported Cinnarizine’s proactive role in the prevention of vertiginous spells, particularly in Meniere’s disease patients with migraine. A retrospective study also suggested the safety and efficacy of Cinnarizine in decreasing both headache and vertigo components in patients with migrainous vertigo or migraine with brainstem aura associated with vertigo.
Acute Vestibular Dysfunction
Antiemetic medications (eg Prochlorperazine) may be given for nausea and vomiting control. Methylprednisolone as an acute treatment may be considered to improve functional vestibular recovery. Vestibular blocking or suppressant agents (eg Dimenhydrinate) may be given to reduce the spinning sensation. Acetyl-DL-leucine has been used in clinical practice to reduce imbalance and autonomic manifestations associated with acute vertigo crises. This is commonly used for cerebellar disequilibrium and nystagmus.
Nonpharmacological
Vertigo management is usually comprised of symptomatic and non-pharmacological therapy. Acute and severe episodes of vertigo, regardless of the underlying cause, will usually settle in 24-48 hours due to the effect of brainstem compensation.
Benign Paroxysmal Positional Vertigo (BPPV)
Observation
Observation is the initial therapy for benign paroxysmal positional vertigo. “Watchful waiting” or postponing particle repositioning maneuvers (PRMs) and/or vestibular rehabilitation to see if the symptoms of benign paroxysmal positional vertigo will take their natural spontaneous course of improvement. Positions or activities that would induce vertigo attacks should be avoided by the patient during the course of observation.
Particle Repositioning Maneuvers (PRMs)
Different maneuvers that can be done to move the canaliths from the semicircular canal to the vestibule from which they are absorbed. These can consistently eliminate vertigo due to benign paroxysmal positional vertigo, improve quality of life, and reduce risks of falling.
Posterior Canal-BPPV
Canalith repositioning procedure (CRP or Epley maneuver) is an effective and safe therapy that should be offered to patients of all ages with posterior semicircular canal BPPV. This maneuver moves the canaliths from the posterior semicircular canal to the vestibule, thus relieving the stimulus from the semicircular canal that has been producing the BPPV. Nausea, occasional vomiting, and/or a sense of falling may arise during the procedure. This provides short-term relief of symptoms of posterior canal BPPV. The success of a single treatment is 50-90%, while repeated CRPs over time approach a 100% success rate. This is the recommended modality for initial treatment failure due to persistent BPPV. Canalith repositioning procedure should not be done in patients with severe carotid stenosis, unstable heart disease, or severe neck pathology (eg cervical spondylosis with myelopathy or advanced rheumatoid arthritis).
The Semont maneuver (Liberatory maneuver) is the maneuver that moves the debris from the posterior semicircular canal back into the vestibule by breaking the canaliths free from adherence to the cupula and/or repositioning free-floating canaliths. Recent studies have shown comparable effectiveness with CRP.
Vertigo_Management 2Horizontal Canal-BPPV
The Gufoni maneuver is an effective treatment for horizontal canal BPPV.
Vertigo_Management 3The roll maneuver is also called the Lempert 360° roll maneuver or barbecue roll maneuver. This is a moderately effective and widely used treatment for lateral canal BPPV.
Vertigo_Management 4Forced prolonged positioning is an option for refractory horizontal canal BPPV but with high remission rates. This position allows the otoconia to fall out of the horizontal canal.
Vestibular Rehabilitation
Physical therapy is composed of habituation exercises and home repositioning exercises performed by the patient for the treatment of benign paroxysmal positional vertigo with or without direct clinician supervision. This is as effective as PRMs in bringing symptom resolution in posterior canal BPPV. This is indicated for patients who have persistent disability after a canalith repositioning procedure, refuse or are not candidates for CRP, patients needing additional therapy to resolve non-specific dizziness, and patients with increased risk of falling.
Habituation Exercises or Cawthorne and Cooksey Exercises
Habituation exercises, or Cawthorne and Cooksey exercises, start with simple head movements performed in a sitting or supine position. This then progresses to complex activities, including walking on slopes and steps with eyes open and closed and sports activities requiring eye-hand coordination. These exercises will cause fatigue in the vestibular response and will force the central nervous system to compensate by habituation to the stimulus.
Home Repositioning Exercise or Brandt-Daroff Maneuver
The patient starts in a sitting position and moves quickly to the right-side-lying position with the head rotated 45° and facing upward. The position is maintained for 30 seconds after the vertigo stops. The patient then moves rapidly to a left-side-lying position, with the head rotated 45° and facing upward. This exercise will promote loosening and ultimately dispersion of debris toward the utricular cavity.
Meniere’s Disease
Lifestyle Modification
To lower endolymphatic pressure, patients are advised to follow a low-salt diet (<1-2 g/day) and a diet that includes potassium and protein; hydrate adequately with water; limit alcohol intake to one drink/day; and avoid smoking.
Rehabilitation
Vestibular rehabilitation exercises train the brain to use alternative visual and proprioceptive cues to maximize balance and central nervous system compensation for imbalance. A hearing aid in the affected ear helps in improving hearing problems.
Meniett Device
A Meniett device is a positive pressure pulse generator and a device that applies intermittent positive pressure to the ear canal through a ventilation tube that helps to improve fluid exchange in the inner ear. It is being done at home for 5 minutes at a time, usually 3x/day. Initial reports show improvement of symptoms of Meniere’s disease, but the device is expensive.
Acute Vestibular Dysfunction
Bed Rest
Bed rest is important in the acute phase of vestibulopathy.
Vestibular Rehabilitation Exercises
Vestibular rehabilitation exercises may be done for more rapid and complete compensation of vestibular function. These are shown to speed up recovery and improve disability in patients with permanent vestibular injury.
Surgery
Meniere’s Disease
Surgery is recommended if conservative and medical treatments have failed, and the disease is severe.
Endolymphatic Duct or Sac Procedures and Sacculotomy
The procedure exposes the endolymphatic sac and duct with the aim of improving endolymph drainage. This is commonly done in Meniere’s disease patients with intact hearing. Control of vertigo has been reported in 75-80% in an uncontrolled case series. There is a low risk of sensorineural hearing loss.
Vestibular Nerve Section or Vestibular Neurectomy
The vestibular nerve bundle is surgically lysed as it enters the internal auditory canal. This relieves vertigo in 90-95% of patients. There is a low risk of sensorineural hearing loss.
Labyrinthectomy
Neuroepithelium of the bony and membranous labyrinth is surgically removed, thus eliminating both balance and hearing function from the affected ear. Due to the irreversible hearing loss, this procedure is reserved for patients with intractable symptoms despite pharmacotherapy and with poor hearing or complete hearing loss on the affected side.