Vertigo medical therapy: Difference between revisions

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==Medical Therapy==
__NOTOC__
===Central disorders===
{{Vertigo}}
*:* ''Treat underlying disease''
{{CMG}} {{AE}} {{ZMalik}}
*:* Vertebrobasilar ischemia
*:*:* Vertigo usually resolves on its own
*:*:* Risk factor modification to decrease recurrence
*:*:* +/- Revascularization or anticoagulation
*:* Migraine:  adequate treatment of headache improves vertigo in 90%
*:* Multiple sclerosis (MS):  Therapy for MS alleviates vertiginous symptoms as well
*:* Drugs:  discontinue offending agents
* '''Peripheral disorders''' 
*:* ''General management''
*:* Physical therapy 
*:*:* Beneficial in patients with permanent peripheral vestibular dysfunction
*:*:* Unknown benefit in patients with central disorders
*:*:* Vestibular rehabilitation
*:*:*:* Activity enables CNS adaptation to loss of vestibular input
*:*:*:* Visual compensation during head motion
*:*:*:* Balance shown to improve in randomized controlled trials of vestibular exercises
*:*:*:* Unclear if long-term benefits or if decreased fall risk
*:* Avoidance of inactivity
*:*:*:* Avoid deconditioning and loss of postural reflexes


=== Acute Pharmacotherapies ===  
==Overview==
Single drug therapy is usually not effective to minimize the [[symptom]], a combination of [[antihistamine]] and [[antiemetic]] are used to control vertigo. Definitive therapy is treating the underlying cause of vertigo.


* Peripheral disorders 
==Medical Therapy==
:* Specific management
*[[Acute]]/severe attacks of vertigo usually subsides in a day or two after brainstem compensation.<ref name="pmid18523693">{{cite journal| author=Kuo CH, Pang L, Chang R| title=Vertigo - part 2 - management in general practice. | journal=Aust Fam Physician | year= 2008 | volume= 37 | issue= 6 | pages= 409-13 | pmid=18523693 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18523693  }} </ref>
::* BPPV
*Supportive therapy includes bed rest, [[antihistamine]], [[antiemetic]] ([[prochlorperazine]], [[metoclopramide]]), [[benzodiazepines]] ([[diazepam]],[[lorazepam]]) to relief the [[symptom]].
::* Epley maneuver --> in a randomized controlled trial, symptoms resolved in 50% vs. 19% sham therapy by mean 10 days
*[[Meclizine]] is the common [[antihistamine]] used and is safe in [[pregnancy]]. Other [[antihistamines]] used are [[betahistine]] and [[dimenhydrinate]].<ref> Khilnani, AK; Thaddanee, R; Khilnani, G (July 2013). "Anti vertigo drugs-Revisited". National Journal of Integrated Research in Medicine. 4 (4): 118–28.</ref>
::* Meclizine (12.5-50 mg every 6 hours as often as necessary) or promethazine (25 mg every 6 hours as often as necessary) for severe symptoms
*[[Scopolamine]] ([[hyoscine hydrobromide]]) is a common [[anticholinergic]] used to treat the symptom.<ref> Khilnani, AK; Thaddanee, R; Khilnani, G (July 2013). "Anti vertigo drugs-Revisited". National Journal of Integrated Research in Medicine. 4 (4): 118–28.</ref>
::* Meniere’s disease:  low-salt diet and diuretics to reduce endolymph production
*Due to the [[sedative]] effect of these drugs they should be used carefully in the elderly.
*These drugs should not be used for a long period of time as it may delay the compensatory mechanism in the [[brainstem]] and result in the prolongation of vertigo [[symptom]].
*Some patients may be a candidate for [[vestibular]] [[rehabilitation]], it improves balance and decreases [[dizziness]] by exercises that stabilize [[gait]] and [[gaze]].


* Peripheral disorders 
==Treatment for Common Causes of Vertigo==
:*General management
:*  
::*Pharmacologic therapy
{| class="wikitable"
:::*For acute episodes: Avoid long-term therapy if symptoms last > few days (will reduce CNS adaptation)
|+
::::*Anticholinergics
! colspan="2" |Treating Peripheral Vertigo
:::::*Scopolamine: Side effect urinary retention, dry mouth
|-
::::*Antihistamines
![[Ménière’s disease]]
:::::*Meclizine, dimenhydrinate, diphenhydramine (anti-Ach effects)
|
:::::*Meclizine is drug of choice in pregnancy. Side effect: sedation
*Treatment is focused on preventing acute attacks and controlling the excess fluid build-up.
::::*Phenothiazines
*Non-invasive: Low-sodium diet, hearing aid, [[positive pressure therapy]].
:::::*prochlorperazine, promethazine (anti-Ach effects): More sedating, but also have antiemetic effects. Risk: extrapyramidal side effect (second-line)
*Medications: [[Meclizine]], [[diazepam]], [[promethazine]], [[diuretics]]
::::*Benzodiazepines
*Steroid<ref name="PhillipsWesterberg2011">{{cite journal|last1=Phillips|first1=John S|last2=Westerberg|first2=Brian|title=Intratympanic steroids for Ménière's disease or syndrome|journal=Cochrane Database of Systematic Reviews|year=2011|issn=14651858|doi=10.1002/14651858.CD008514.pub2}}</ref> or [[gentamicin]]<ref name="PostemaKingma2009">{{cite journal|last1=Postema|first1=Rolf J.|last2=Kingma|first2=Charlotte M.|last3=Wit|first3=Hero P.|last4=Albers|first4=Frans W.J.|last5=Van Der Laan|first5=Bernard F.A.M.|title=Intratympanic gentamicin therapy for control of vertigo in unilateral Menière's disease: a prospective, double-blind, randomized, placebo-controlled trial|journal=Acta Oto-Laryngologica|volume=128|issue=8|year=2009|pages=876–880|issn=0001-6489|doi=10.1080/00016480701762458}}</ref> injections in middle ear.
:::::*Diazepam, lorazepam, clonazepam (GABA-ergic effects): For patients with contraindications to anti-Ach prescription (benign prostatic hypertrophy)
*Surgery: Decompress [[endolymphatic]] sac, [[labyrinthectomy]], [[Vestibular nerve section]]<ref name="SyedAldren2012">{{cite journal|last1=Syed|first1=I.|last2=Aldren|first2=C.|title=Meniere’s disease: an evidence based approach to assessment and management|journal=International Journal of Clinical Practice|volume=66|issue=2|year=2012|pages=166–170|issn=13685031|doi=10.1111/j.1742-1241.2011.02842.x}}</ref>.
|-
![[Acoustic neuroma]]
|
*Observe if the [[tumor]] is small, [[asymptomatic]], not growing, or in elderly with comorbidities.
*For large, [[symptomatic]], growing [[tumor]] one of the following treatment is helpful after weighing risks and benefits:  
**[[Radiotherapy]]
**[[Radiosurgery]]
**Surgical removal 
|-
![[Benign paroxysmal positional vertigo]]
|
*Effective [[maneuvers]]:[[Epley maneuver]], [[Semont maneuver]], [[Brandt–Daroff exercises]], [[Roll maneuver]].<ref>{{cite journal|journal=Cochrane Database of Systematic Reviews|issn=14651858</ref>
*Medical: [[Antihistamine]]([[meclizine]]) and [[anticholinergic]]([[scopolamine]]).<ref>"Meclizine Hydrochloride Monograph for Professionals". American Society of Health-System Pharmacists. Retrieved 22 March 2019</ref>
*Surgical: For [[resistant]] and severe cases [[occlusion]] of [[semi-circular canal]] may be helpful.
|-
![[Acute]] [[labyrinthitis]]
|
*Depends upon the etiology:
**Viral: [[hydration]], bedrest.<ref name="SeemungalBronstein2008">{{cite journal|last1=Seemungal|first1=B M|last2=Bronstein|first2=A M|title=A practical approach to acute vertigo|journal=Practical Neurology|volume=8|issue=4|year=2008|pages=211–221|issn=1474-7758|doi=10.1136/jnnp.2008.154799}}</ref>
**Bacterial: [[Antibiotic]] depending on the origin of infection that led to [[labyrinthitis]].
|-
![[Acute vestibular neuritis]]
|
*Symptomatic:[[Antiemetic]], [[antihistamine]], [[benzodiazepines]]. These [[medicines]] should not be used for more than three days as the central compensation can get delayed leading to recurrent, [[chronic]] vertigo.<ref name="pmid28145669">{{cite journal| author=Muncie HL, Sirmans SM, James E| title=Dizziness: Approach to Evaluation and Management. | journal=Am Fam Physician | year= 2017 | volume= 95 | issue= 3 | pages= 154-162 | pmid=28145669 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28145669  }} </ref>
*[[Steroid]] efficacy is controversial. <ref name="FishmanBurgess2011">{{cite journal|last1=Fishman|first1=Jonathan M|last2=Burgess|first2=Chris|last3=Waddell|first3=Angus|title=Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)|journal=Cochrane Database of Systematic Reviews|year=2011|issn=14651858|doi=10.1002/14651858.CD008607.pub2}}</ref>
|-
![[Cholesteatoma]]
|
*Surgical removal followed by periodic follow-ups.
|-
![[Otosclerosis]]
|
*Medical: [[Sodium]] [[flouride]] can slow the progression. <ref name="de Oliveira Penidode Oliveira Vicente2018">{{cite journal|last1=de Oliveira Penido|first1=Norma|last2=de Oliveira Vicente|first2=Andy|title=Medical Management of Otosclerosis|journal=Otolaryngologic Clinics of North America|volume=51|issue=2|year=2018|pages=441–452|issn=00306665|doi=10.1016/j.otc.2017.11.006}}</ref>
*Surgical procedure of choice is [[stapedectomy]].<ref name="pmid24303446">{{cite journal| author=Mahafza T, Al-Layla A, Tawalbeh M, Abu-Yagoub Y, Atwan Sulaiman A| title=Surgical Treatment of Otosclerosis: Eight years' Experience at the Jordan University Hospital. | journal=Iran J Otorhinolaryngol | year= 2013 | volume= 25 | issue= 73 | pages= 233-8 | pmid=24303446 | doi= | pmc=3846245 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24303446  }} </ref>
|+
! colspan="2" |Treating Central Vertigo
|-
![[Brainstem]] [[Stroke]]
|
* Folow stroke management protocol.
|-
![[Vestibular]] [[Migraine]]
|
*[[Antiemetic]] coupled with medicines that relieve symptomatic vertigo.<ref name="Sargent2013">{{cite journal|last1=Sargent|first1=Eric W.|title=The challenge of vestibular migraine|journal=Current Opinion in Otolaryngology & Head and Neck Surgery|volume=21|issue=5|year=2013|pages=473–479|issn=1068-9508|doi=10.1097/MOO.0b013e3283648682}}</ref>
|-
![[Multiple Sclerosis]]
|
*Disease-modifying drugs such as [[glatiramer acetate]], [[interferon-beta]], [[natalizumab]], [[mitoxantrone]] are effective in treat relapsing-remitting type.
*For the secondary progressive, progressive-relapsing, and primary progressive type disease-modifying drugs are less effective.
*Acute relapses are managed by treating the triggering cause, symptomatic therapy, [[corticosteroids]], and/or [[rehabilitation]].  
|-
![[Cerebellopontine angle]] [[tumors]]
|
*Observation, [[radiotherapy]], or [[microsurgery]] is selected as a plan of treatment after assessing the size/growth of the [[tumor]], age of the patient, and [[comorbidities]].<ref name="HuangVermeulen2003">{{cite journal|last1=Huang|first1=May Y|last2=Vermeulen|first2=Sandra|title=Clinical perspectives regarding patients with internal auditory canal or cerebellopontine angle lesions: Surgical and radiation oncology perspectives|journal=Seminars in Ultrasound, CT and MRI|volume=24|issue=3|year=2003|pages=124–132|issn=08872171|doi=10.1016/S0887-2171(03)90034-5}}</ref>
|}


=== Surgery and Device Based Therapy ===
==Reference==
* Perilymphatic fistula
{{Reflist|2}}
*:* Bed rest, head elevation, avoidance of straining
{{WH}}
*:* Surgical patch if no resolution after several weeks
{{WS}}
* Acoustic neuroma: surgical therapy

Latest revision as of 16:23, 11 January 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Zehra Malik, M.B.B.S[2]

Overview

Single drug therapy is usually not effective to minimize the symptom, a combination of antihistamine and antiemetic are used to control vertigo. Definitive therapy is treating the underlying cause of vertigo.

Medical Therapy

Treatment for Common Causes of Vertigo

Treating Peripheral Vertigo
Ménière’s disease
Acoustic neuroma
Benign paroxysmal positional vertigo
Acute labyrinthitis
Acute vestibular neuritis
Cholesteatoma
  • Surgical removal followed by periodic follow-ups.
Otosclerosis
Treating Central Vertigo
Brainstem Stroke
  • Folow stroke management protocol.
Vestibular Migraine
  • Antiemetic coupled with medicines that relieve symptomatic vertigo.[14]
Multiple Sclerosis
Cerebellopontine angle tumors

Reference

  1. ↑ Kuo CH, Pang L, Chang R (2008). "Vertigo - part 2 - management in general practice". Aust Fam Physician. 37 (6): 409–13. PMID 18523693.
  2. ↑ Khilnani, AK; Thaddanee, R; Khilnani, G (July 2013). "Anti vertigo drugs-Revisited". National Journal of Integrated Research in Medicine. 4 (4): 118–28.
  3. ↑ Khilnani, AK; Thaddanee, R; Khilnani, G (July 2013). "Anti vertigo drugs-Revisited". National Journal of Integrated Research in Medicine. 4 (4): 118–28.
  4. ↑ Phillips, John S; Westerberg, Brian (2011). "Intratympanic steroids for Ménière's disease or syndrome". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD008514.pub2. ISSN 1465-1858.
  5. ↑ Postema, Rolf J.; Kingma, Charlotte M.; Wit, Hero P.; Albers, Frans W.J.; Van Der Laan, Bernard F.A.M. (2009). "Intratympanic gentamicin therapy for control of vertigo in unilateral Menière's disease: a prospective, double-blind, randomized, placebo-controlled trial". Acta Oto-Laryngologica. 128 (8): 876–880. doi:10.1080/00016480701762458. ISSN 0001-6489.
  6. ↑ Syed, I.; Aldren, C. (2012). "Meniere's disease: an evidence based approach to assessment and management". International Journal of Clinical Practice. 66 (2): 166–170. doi:10.1111/j.1742-1241.2011.02842.x. ISSN 1368-5031.
  7. ↑ {{cite journal|journal=Cochrane Database of Systematic Reviews|issn=14651858
  8. ↑ "Meclizine Hydrochloride Monograph for Professionals". American Society of Health-System Pharmacists. Retrieved 22 March 2019
  9. ↑ Seemungal, B M; Bronstein, A M (2008). "A practical approach to acute vertigo". Practical Neurology. 8 (4): 211–221. doi:10.1136/jnnp.2008.154799. ISSN 1474-7758.
  10. ↑ Muncie HL, Sirmans SM, James E (2017). "Dizziness: Approach to Evaluation and Management". Am Fam Physician. 95 (3): 154–162. PMID 28145669.
  11. ↑ Fishman, Jonathan M; Burgess, Chris; Waddell, Angus (2011). "Corticosteroids for the treatment of idiopathic acute vestibular dysfunction (vestibular neuritis)". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD008607.pub2. ISSN 1465-1858.
  12. ↑ de Oliveira Penido, Norma; de Oliveira Vicente, Andy (2018). "Medical Management of Otosclerosis". Otolaryngologic Clinics of North America. 51 (2): 441–452. doi:10.1016/j.otc.2017.11.006. ISSN 0030-6665.
  13. ↑ Mahafza T, Al-Layla A, Tawalbeh M, Abu-Yagoub Y, Atwan Sulaiman A (2013). "Surgical Treatment of Otosclerosis: Eight years' Experience at the Jordan University Hospital". Iran J Otorhinolaryngol. 25 (73): 233–8. PMC 3846245. PMID 24303446.
  14. ↑ Sargent, Eric W. (2013). "The challenge of vestibular migraine". Current Opinion in Otolaryngology & Head and Neck Surgery. 21 (5): 473–479. doi:10.1097/MOO.0b013e3283648682. ISSN 1068-9508.
  15. ↑ Huang, May Y; Vermeulen, Sandra (2003). "Clinical perspectives regarding patients with internal auditory canal or cerebellopontine angle lesions: Surgical and radiation oncology perspectives". Seminars in Ultrasound, CT and MRI. 24 (3): 124–132. doi:10.1016/S0887-2171(03)90034-5. ISSN 0887-2171.

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