vertigo
VERTIGO

Vertigo is having a sensation of spinning of either the surrounding or within oneself but physical movement does not exist.

It may be secondary to different causes that may be determined by numerous factors eg timing and duration, aggravating conditions or associated symptoms.
Central vertigo originates from the central nervous system (brainstem or cerebellum). It is uncommon but more serious and should be ruled out immediately.
Peripheral vertigo originates from the labyrinth or vestibular nerve.

Pharmacotherapy

Benign Paroxysmal Positional Vertigo

  • Medications are not routinely given in benign paroxysmal vertigo other than in patients with severe vegetative symptoms such as nausea or vomiting

Meniere’s disease

  • Antiemetic medications (eg Metoclopramide, Promethazine, Prochlorperazine) for nausea and vomiting control
  • Diuretics (combination of Hydrochlorothiazide and Triamterene) helps lower endolymphatic pressure
  • Betahistine and labyrinth ablation therapies with intratympanic Gentamicin also aids in lowering endolymphatic pressure
  • Intratympanic glucocorticoids showed some benefit in patients with intractable unilateral Meniere’s disease
  • Vestibular blocking/suppressant agents (eg Meclizine, Betahistine, Dimenhydrinate, Diazepam, Glycopyrrolate, Lorazepam) to reduce the spinning sensation
  • Antistamines 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) for nausea and vomiting control
  • Methylprednisolone as acute treatment to improve functional vestibular recovery
  • Vestibular blocking/suppressant agents (eg Dimenhydrinate) 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
    • Commonly used for cerebellar disequilibrium and nystagmus

Non-Pharmacological Therapy

  • 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 24-48 hours due to the effect of brainstem compensation

Benign Paroxysmal Positional Vertigo (BPPV)

Observation

  • Initial therapy for benign paroxysmal vertigo
  • “Watchful waiting” or postponing particle repositioning maneuvers (PRMs) and/or vestibular rehabilitation to see if the symptoms of benign paroxysmal vertigo will take its natural spontaneous course of improvement
  • Positions or activities that would induce vertigo attack 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
  • Can consistently eliminate vertigo due to benign paroxysmal vertigo, improve quality of life and reduce risks of falling
  • Canalith repositioning procedure (CRP or Epley maneuver)
    • An effective and safe therapy that should be offered to patients of all ages with posterior semicircular canal benign paroxysmal vertigo
    • Maneuver that moves the canaliths from the posterior semicircular canal to the vestibule, thus relieving the stimulus from the semicircular canal that have been producing the benign paroxysmal vertigo
    • Nausea, occasional vomiting and/or sense of falling may arise during the procedure
    • Provides a short-term relief of symptoms of posterior canal benign paroxysmal vertigo
    • Success of single treatment is 50-90% while repeated CRPs over time approaches 100% success rate
    • Recommended modality for initial treatment failure due to persistent benign paroxysmal positional vertigo
    • CRP should not be done in patients with severe carotid stenosis, unstable heart disease, severe neck pathology (eg cervical spondylosis with myelopathy or advanced rheumatoid arthritis)
  • Semont maneuver (Liberatory maneuver)
    • 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 reposition free-floating canaliths 
    • Recent studies have shown comparable effectiveness with CRP
  • Gufoni maneuver
    • Effective treatment for horizontal canal benign paroxysmal vertigo
  • Forced prolonged positioning
    • An option for refractory horizontal canal benign paroxysmal vertigo but with high remission rates
    • This position allows the otoconia to fall out of the horizontal canal
  • Roll maneuver
    • Lempert 360° roll maneuver or barbecue roll maneuver
    • Moderately effective and widely used treatment for lateral canal benign paroxysmal vertigo
  • Vannuchi-Asprella liberatory maneuver
    • May be effective for lateral canal benign paroxysmal vertigo but there are limited clinical studies regarding use

Vestibular Rehabilitation

  • Physical therapy composed of habituation exercises and home repositioning exercises performed by the patient for the treatment of benign paroxysmal vertigo with or without direct clinician supervision
  • As effective as PRMs in bringing symptom resolution in posterior canal benign paroxysmal vertigo
  • Indicated for patients who have persistent disability after CRP, refuse or are not candidates for CRP, patients needing additional therapy to resolve non-specific dizziness and patients with increased risk of fall
  • Habituation exercise
    • Start with simple head movements, performed in sitting or supine position
    • Then progress 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 (CNS) to compensate by habituation to the stimulus
  • Home repositioning exercise/Brandt-Daroff Maneuver
    • The patient starts in a sitting position and moves quickly to the right-side lying position with the head rotated 45 degrees 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 degrees and facing upward
    • This exercise will promote loosening and ultimately dispersion of debris toward the utrical cavity

Meniere’s Disease

Lifestyle Modification

  • To lower endolymphatic pressure:
    • Observe low salt diet (<1-2 g/day)
    • Avoid intake of caffeinated beverages (eg cola, coffee or tea)
    • Limit alcohol intake to 1 drink/day
    • Avoid smoking

Rehabilitation

  • Vestibular rehabilitation exercises train the brain to use alternative visual and proprioceptive cues to maximize balance and CNS compensation for imbalance
  • Hearing aid to the affected ear helps in improving hearing problems

Meniett Device

  • Positive pressure pulse generator
  • 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

  • Important in the acute phase of vestibulopathy

Vestibular Rehabilitation Exercises

  • For more rapid and complete compensation of vestibular function
  • Shown to speed up recovery and improve disability in patients with permanent vestibular injury
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