Vertigo medical therapy
Medical Therapy
Central disorders
- Treat underlying disease
- 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
- Peripheral disorders
- Specific management
- BPPV
- Epley maneuver --> in a randomized controlled trial, symptoms resolved in 50% vs. 19% sham therapy by mean 10 days
- 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
- Meniere’s disease: low-salt diet and diuretics to reduce endolymph production
- Peripheral disorders
- General management
- Pharmacologic therapy
- For acute episodes: Avoid long-term therapy if symptoms last > few days (will reduce CNS adaptation)
- Anticholinergics
- Scopolamine: Side effect urinary retention, dry mouth
- Antihistamines
- Meclizine, dimenhydrinate, diphenhydramine (anti-Ach effects)
- Meclizine is drug of choice in pregnancy. Side effect: sedation
- Phenothiazines
- prochlorperazine, promethazine (anti-Ach effects): More sedating, but also have antiemetic effects. Risk: extrapyramidal side effect (second-line)
- Benzodiazepines
- Diazepam, lorazepam, clonazepam (GABA-ergic effects): For patients with contraindications to anti-Ach prescription (benign prostatic hypertrophy)
Surgery and Device Based Therapy
- Perilymphatic fistula
- Bed rest, head elevation, avoidance of straining
- Surgical patch if no resolution after several weeks
- Acoustic neuroma: surgical therapy