That spinning feeling: What treatments actually work for vertigo?
Key Takeaways
When encountering vertigo, clinicians should first rule out central causes, such as stroke. Research shows that peripheral etiologies such as benign paroxysmal positional vertigo (BPPV) are more common than central causes, with BPPV, Ménière disease, and vestibular migraine possibly existing on a spectrum.
There are limited pharmacologic options for vertigo; vestibular rehabilitation is an effective non-drug approach, according to research.
Multidisciplinary teams and specialty centers may be the best resources in addressing complicated cases of vertigo.
Vertigo is a complaint that is experienced by patients of all ages, with older patients especially prone to falls.
This sensation most often presents as rotational motion and must be differentiated from other types of dizziness, such as lightheadedness, which can indicate presyncope, according to research published in StatPearls.[]
Causes of vertigo
Vertigo is a symptom of dysfunction of the vestibular system. It can be due to either peripheral causes, such as benign paroxysmal positional vertigo (BPPV) and Ménière disease, or central causes, such as hemorrhagic stroke to the cerebellum or vertebrobasilar system, as per the StatPearls research.
In addition to stroke, central causes of vertigo include brainstem glioma, medulloblastoma, and vestibular schwannoma, which also causes sensorineural hearing loss. Vestibular migraines can also be to blame, and present with unilateral headaches, as well as nausea, vomiting, phonophobia, and photophobia, according to StatPearls.
The central causes are dangerous and require immediate diagnosis and treatment. They should be considered a differential diagnosis and mandate close attention to history, physical, and diagnostic tests.
Of the common peripheral causes, BPPV arises from calcium deposits or debris that accumulates in the posterior semicircular canal and leads to frequent transient episodes of vertigo, which lasts a few minutes or less.
Individuals with Ménière disease also struggle with tinnitus, hearing loss, and aural fullness. Endolymphatic hydrops is pathognomonic for Ménière disease, with symptoms stemming from excess endolymph in the semicircular canals.
Other possible causes of peripheral vertigo include acute labyrinthitis and vestibular neuritis, which result from inflammation. This inflammation is often due to a viral infection.
Multiple sclerosis (MS) can lead to both central and peripheral vertigo. In terms of central causes, MS gives rise to demyelinating plaques in the vestibular system, whereas BPPV can lead to peripheral causes of vertigo in patients with MS.
Medications such as anticonvulsants and mood disorders can also result in vertigo.
Research on peripheral causes
In a study published in Frontiers in Neurology, Dutch researchers examined the course of vertigo attacks in patients with benign recurrent vertigo (BRV) vs patients with Ménière disease or vestibular migraine and suggested that these conditions may lie on a spectrum.[]
In the prospective cohort study, they found that BRV usually exhibited good prognoses, with the attacks ceasing in 71% of patients within 3 years. Similar rates of clinical remission were noted in patients with Ménière disease or vestibular migraine, with the clinical course similar in all three groups.
"We assume that BRV is a mild or incomplete variant of VM and MD, rather than a separate disease entity with distinct pathognomonic features."
— van Leeuwen, et al., Frontiers in Neurology
“The practical significance of our findings is that, in our view, patients who are diagnosed with BRV can be informed that their prognosis in terms of vertigo attacks is rather favorable, and also that it is unlikely that it will further develop into MD,” the authors added.
Pharmacologic treatment
Vertigo treatment is typically focused on addressing the underlying cause to lessen the symptoms, according to the StatPearls research.
Acute vestibular symptoms can be treated with antihistamines, antiemetics, and benzodiazepines. Meclizine is the antihistamine most commonly used to treat vertigo and can be taken during pregnancy. However, these drugs can cause sedating effects and thereby pose potential danger to older patients.
In cases of visual vertigo, which refers to vertiginous symptoms (including unsteadiness, disorientation, and discomfort) that arise from visual triggers, evidence points to the clinical utility of acetazolamide. Typically, visual vertigo is treated with vestibular rehabilitation only.
According to the authors of a study published in Neuro-Ophthalmology, “The atrophied cerebellum may be unable to process the plethora of moving visual stimuli, thus creating a sensation of vertigo and overall discomfort.”[]
"Acetazolamide has been shown to improve visual stimuli recognition and processing when compared with controls. Therefore, it is possible that acetazolamide may act directly on the cerebellar visual processing centre and enhancing its filtering function."
— Slush, et al., Neuro-Ophthalmology
Patients with Ménière disease could be responsive to decreases in dietary salt, caffeine, and alcohol intake, which are known triggers. Diet modification can also be combined with diuretics.
Non-pharmacologic treatments
Vestibular rehabilitation exercises may be helpful for patients with permanent vestibular dysfunction. These exercises condition the brain via alternative visual and proprioceptive clues to help the patient maintain balance. Clinical trials have shown that such exercises can reduce vertiginous symptoms and improve activities of daily living.
The primary strategy for treating BPPV involves head-rotation maneuvers. These exercises displace calcium deposits and return them to the vestibule via canalith repositioning or the Epley maneuver. The latter can be performed by the patient at home.
Multidisciplinary care
Vertigo is a complex presentation that may best be addressed by multidisciplinary teams including primary care doctors, neurologists, otolaryngologists, physical therapists, specialty nurses, and pharmacists, according to StatPearls.
Some patients may require detailed imaging and specialist care (although many can be diagnosed clinically).
Otolaryngologists and neuroscience nurses can coordinate testing, monitor response, relay results, and educate patients.
Specialty centers such as the University of California San Francisco Balance and Falls Center serve as one-stop shops for multidisciplinary diagnosis, treatment, and support.[]
What this means for you
In addition to being remarkably common, vertigo can also be dangerous. Central causes should always be ruled out first. Depending on the cause, vestibular rehabilitation and symptomatic treatment may help alleviate symptoms. When in doubt, it’s a good idea to involve multidisciplinary teams in the treatment of this condition.