How long does it take for vertigo to clear up?

Contents

Vertigo Treatment: Getting Rid of the Spins

The treatment you’ll get for vertigo symptoms will depend on what’s causing them.

An optokinetic ball is used in vestibular rehabilitation, a technique that helps patients learn to use other senses (in this case vision) to compensate for vertigo. Alamy

Numerous treatments are available to help the dizzy and spinning sensations that people with vertigo experience. Sometimes vertigo goes away without any treatment.

Options range from medication to specific exercises to surgery.

Your healthcare provider can help you determine which therapies are likely to help your symptoms.

Physical therapy to improve balance and inner ear issues

Vestibular rehabilitation is a type of physical therapy that can benefit people with inner ear or balance problems. It helps your brain learn ways to use other senses (such as vision) to compensate for vertigo.

The exercises are typically customized to meet a person’s individual needs. They may include eye and head movements, balance training, or other maneuvers, depending on what’s causing your symptoms.

Vestibular rehabilitation is usually performed on an outpatient basis, but it can also be done in a hospital or home setting. (1)

Canalith Repositioning—also known as the Epley Maneuver

Canalith repositioning, also known as the “Epley maneuver,” is a technique that involves a series of special head and body movements.

The purpose is to move crystals from the fluid-filled semicircular canals of your inner ear to a different area, so they can be absorbed by the body.

Canalith repositioning involves the following steps:

  1. You sit on an exam table with your eyes open and your head turned 45 degrees to the right.
  2. You lie on your back quickly with your head hanging off the end of the table.
  3. Your doctor turns your head 90 degree to the left, and you hold this position for about 30 seconds.
  4. Your physician turns your head another 90 degrees to the left while you rotate your body in the same direction. This position is held for another 30 seconds.
  5. You sit up on the left side of the exam table.
  6. The procedure can be repeated on both sides until you feel relief.

You’ll probably have symptoms of vertigo during your treatment. You might need to remain upright for 24 hours following your procedure to prevent crystals from returning to the semicircular canals.

A doctor or physical therapist typically performs canalith repositioning, but you may be shown how to do modified exercises at home.

Canalith repositioning is very effective for people with benign paroxysmal positional vertigo (BPPV) — the most common cause of vertigo. Results vary, but some studies have shown between a 50 and 90 percent success rate. (2)

If the crystals move back into your semicircular canals, your doctor can repeat the treatment.

You should tell your healthcare provider if you have any of the following before having this therapy:

  • A neck problem
  • A back condition
  • Rheumatoid arthritis
  • A detached retina in your eye
  • Blood vessel or heart problems (3,4)

Related: YouTube Videos May Help Some Vertigo Patients

Medication that targets the cause of our symptoms

Various medicines are used to help improve symptoms of vertigo. Drugs are typically more effective at treating vertigo that lasts a few hours to several days.

People with Ménière’s disease may benefit from taking diuretics, medicines that help your body get rid of salt and water.

If your vertigo is caused by an infection, antibiotics or steroids may be given.

Sometimes doctors recommend antihistamines, such as Antivert (meclizine), Benadryl (diphenhydramine), or Dramamine (dimenhydrinate) to help vertigo episodes. Anticholinergics, such as the Transderm Scop patch, may also help with dizziness.

Anti-anxiety meds, like Valium (diazepam) and Xanax (alprazolam) may help relief vertigo in some people, especially if symptoms are triggered by an anxiety disorder.

If your vertigo is caused by a stroke, you may need drugs, such as aspirin, Plavix (clopidogrel), Aggrenox (aspirin-dipyridamole), or Coumadin (warfarin) to prevent a future event.

Certain medication to treat migraines may also help vertigo symptoms in some people. These might include various medicines from different drug classes, such as antidepressants, beta-blockers, selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, anti-emetics, or calcium channel blockers.

Several other medicines are used to help symptoms of vertigo. Check with your doctor to see which drugs might be appropriate for your particular condition. (2)

Surgery—an uncommon treatment for special cases

Surgery isn’t a common treatment for vertigo, but it’s sometimes needed.

You might require a surgical procedure if your symptoms are caused by an underlying condition, such as a tumor or an injury to your brain or neck.

In rare circumstances, doctors may suggest canal plugging surgery for people with BPPV when other treatments fail. With this procedure, a bone plug is used to block an area of your inner ear and prevent the semicircular canals from responding to particle movements. The success rate is around 90 percent. (3)

Another surgery, called labyrinthectomy, disables the vestibular labyrinth in your bad ear and allows the other ear to control balance. This procedure is rarely done but may be recommended if you have significant hearing loss or vertigo that hasn’t responded to other therapies.

Rarely, people with Meniere’s disease may also require surgery, such as a shunt surgery, to help symptoms.

A procedure to plug a leak in the inner ear is sometimes used for individuals with perilymph fistula.

Other surgical procedures may be necessary, depending on what’s causing your vertigo episodes.

Injections—when other treatments haven’t worked

In cases in which patients have not responded to other treatments, injections are sometimes used to help people with vertigo symptoms. The antibiotic Gentamicin (garamycin) can be injected into your inner ear to disable balance. This allows the unaffected ear to perform the balance functions.

Psychotherapy can help alleviate the stress of symptoms

Some people with vertigo may benefit from psychotherapy, even if their symptoms aren’t caused by a psychiatric disorder. (4)

Psychotherapy, also known as “talk therapy,” helps you identify negative behaviors and replace them with positive solutions. There are several different types of psychotherapy.

You may need to be treated for an underlying problem

Your doctor might recommend other treatments for your vertigo, depending on the underlying problem that’s causing your symptoms.

For instance, people with conditions such as heart disease, diabetes, multiple sclerosis (MS), Parkinson’s disease, and anemia may develop vertigo. You might need specific treatments to target these diseases.

Related: The Most Surprising Symptoms of Multiple Sclerosis

Sometimes vertigo goes away all on its own

Your vertigo may go away on its own, with no specific treatment. For instance, people with BPPV often notice that their symptoms disappear within a few weeks or months. (3)

Your doctor can help you figure out if treatment is necessary for your condition.

Home Epley Maneuver

What is the home Epley maneuver?

The home Epley maneuver is a type of exercise help that helps to treat the symptoms of benign paroxysmal positional vertigo (BPPV). You can do this exercise at home.

BPPV is caused by a problem in your inner ear. Your semicircular canals are found inside your ear. They detect motion and send this information to your brain. The utricle is a nearby part of the ear. It contains calcium crystals (canaliths) that help it detect movement.

Sometimes these crystals detach from the utricle and end up inside the semicircular canals. When these crystals move inside the canals, they may send incorrect signals to your brain about your position. This can make you feel like the world is spinning. This is called vertigo.

Dr. John Epley designed a series of movements to dislodge the crystals from the semicircular canals. These movements bring the crystals back to the utricle, where they belong. This treats the symptoms of vertigo.

The original Epley maneuver was designed to be done with a healthcare provider. The home Epley maneuver is similar. These are a series of movements that you can do without help, in your own home.

Why might I need the home Epley maneuver?

You may need to try the home Epley maneuver if you have symptoms of BPPV. In BPPV, vertigo may come on with certain head movements. It may last for up to a minute. These symptoms may be more frequent at times. You may also have nausea and vomiting.

Often BPPV happens without any known cause. Sometimes there is a cause. Causes of BPPV can include:

  • A head injury
  • Problems after ear surgery

The home Epley maneuver is safe and inexpensive. It often works well to treat the symptoms of BPPV.

Your healthcare provider may suggest the home Epley maneuver if your health history and physical exam support that you have BBPV. Your healthcare provider may also suggest that you see a vestibular therapist for treatment.

Your healthcare provider may first do the original Epley maneuver in his or her office. He or she may teach you the home Epley maneuver. You may need to do the home Epley maneuver if you still have symptoms after you leave your healthcare provider’s office. It may also be useful to know how to do this maneuver if your BPPV comes back after a few months or years.

What are the risks of home Epley maneuver?

The home Epley maneuver is safe. It may be helpful to have someone at home with you while you go through the movements. This can give you peace of mind in case your vertigo gets worse in the middle of the treatment.

People with health conditions that limit their ability to move may not be able to do the home Epley maneuver safely. These issues can include neck or back disease, vascular conditions, and retinal detachment. Ask your healthcare provider if the home Epley maneuver is safe for you.

How do I get ready for the home Epley maneuver?

You can do the home Epley maneuver on a bed. You start by sitting on the bed. You need to have a pillow in place so that when you lie back it will be under your shoulders.

What happens during the home Epley maneuver?

You may find it helpful to watch a video of the home Epley maneuver first. Or read a brochure with pictures.

Your healthcare provider will tell how often to do this procedure. He or she may ask you to do it 3 times a day until your symptoms have been gone for 24 hours. Your healthcare provider will also tell if your right or left ear is causing your symptoms.

Follow these steps if the problem is with your right ear:

  • Start by sitting on a bed.
  • Turn your head 45 degrees to the right.
  • Quickly lie back, keeping your head turned. Your shoulders should now be on the pillow, and your head should be reclined. Wait 30 seconds.
  • Turn your head 90 degrees to the left, without raising it. Your head will now be looking 45 degrees to the left. Wait another 30 seconds.
  • Turn your head and body another 90 degrees to the left, into the bed. Wait another 30 seconds.
  • Sit up on the left side.

Follow these steps if the problem is with your left ear:

  • Start by sitting on a bed.
  • Turn your head 45 degrees to the left.
  • Quickly lie back, keeping your head turned. Your shoulders should now be on the pillow, and your head should be reclined. Wait 30 seconds.
  • Turn your head 90 degrees to the right, without raising it. Your head will now be looking 45 degrees to the right. Wait another 30 seconds.
  • Turn your head and body another 90 degrees to the right, into the bed. Wait another 30 seconds.
  • Sit up on the right side.

What happens after the home Epley maneuver?

Most people say their symptoms go away right after they do the maneuver. In some cases, it may take a few times for the procedure to work. Some people may have mild symptoms for a couple of weeks. Once your symptoms go away, there is no need to keep doing the maneuver.

Your healthcare provider may suggest avoiding certain positions for a while after your symptoms have gone away. For instance, you may need to sleep propped up on 2 pillows, to keep your neck from extending straight.

If you still have symptoms after doing the home Epley maneuver, call your healthcare provider. You may not be doing the maneuver the right way. Or you may have another problem that’s causing your symptoms of vertigo. The home Epley maneuver only works to treat vertigo from BPPV. But many other conditions can cause vertigo.

You should be able to be active after doing the home Epley maneuver. Make sure your vertigo has really gone away before doing anything dangerous, such as driving.

With the help of the home Epley maneuver, your vertigo may go away for weeks or even years. BPPV often comes back, though. This might happen if another calcium crystal ends up in your semicircular canals. If your vertigo comes back, do home Epley maneuver again to see if your symptoms go away. If the maneuver doesn’t work, call your healthcare provider.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
    Who to call after the test or procedure if you have questions or problems
  • How much will you have to pay for the test or procedure

This kind of vertigo occurs more frequently in older adults, apparently because the protein coating that holds the crystals in place weakens with age. “Like an old Post-it note, after 60 or 70 years the stickiness wears off,” said Dr. Carol Foster, an otolaryngologist who directs the Balance Laboratory at the University of Colorado Hospital.

Mercifully, the dizziness often resolves on its own within a few days or a couple of weeks. That also makes it difficult to calculate how many people suffer from vertigo, since some never seek treatment or get a correct diagnosis if they do.

When Dr. Oghalai and his colleagues evaluated 100 patients who came to a geriatrics clinic at Baylor College of Medicine over two weeks, none of whom had previously reported dizziness, they found that 9 percent had undiagnosed B.P.P.V. Balance experts think it is even more widespread.

Though the vertigo itself isn’t dangerous, the Baylor study found that patients who had it were more likely to fall, which can cause serious injuries, and were less able to handle daily activities like bathing and dressing. They were also more likely to have received a depression diagnosis.

If the vertigo persists, “it can be very debilitating,” said Dr. Susan Herdman, professor emerita of rehabilitation medicine at Emory University. Some patients come in feeling so unsteady that they are holding onto walls and furniture, or even using a wheelchair.

On average, patients with this disorder have already visited five other physicians before they arrive at Emory’s Dizziness and Balance Center, Dr. Herdman said.

Along the way, they may have undergone lots of expensive, unnecessary tests. They may also have been taking prescription anti-nausea drugs for months, or even years, which may slow the perceived spiraling but don’t stop the vertigo.

Medication

Can Medication Help Me Feel Better?

The use of medication in treating vestibular disorders depends on whether the vestibular system dysfunction is in an initial or acute phase (lasting up to 5 days) or chronic phase (ongoing).

During the acute phase, and when other illnesses have been ruled out, medications that may be prescribed include vestibular suppressants to reduce motion sickness or anti-emetics to reduce nausea. Vestibular suppressants include three general drug classes: anticholinergics, antihistamines, and benzodiazepines. Examples of vestibular suppressants are meclizine and dimenhydinate (antihistamine-anticholinergics) and lorazepam and diazepam (benzodiazepines).

Other medications that may be prescribed are steroids (e.g., prednisone), antiviral drugs (e.g., acyclovir), or antibiotics (e.g., amoxicillin) if a middle ear infection is present. If nausea has been severe enough to cause excessive dehydration, intravenous fluids may be given.

During the chronic phase, symptoms must be actively experienced without interference in order for the brain to adjust, a process called vestibular compensation. Any medication that makes the brain sleepy, including all vestibular suppressants, can slow down or stop the process of compensation. Therefore, they are often not appropriate for long-term use. Physicians generally find that most patients who fail to compensate are either strictly avoiding certain movements, using vestibular suppressants daily, or both.

Pharmacologic Treatment Of Vestibular Disorders

By Dario A. Yacovino, MD (Neuro-Otology Department. Neurology Research Institute “Dr. Raul Carrea” (FLENI), Buenos Aires, Argentina) and Leonel Luis, MD (Clinical Physiology Translational Unit, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, Portugal, and Otolaryngology Department, Hospital de Santa Maria, Lisbon, Portugal)

INTRODUCTION

Vertigo and dizziness are among the most common complaints, having a lifetime prevalence of about 30%1. They are symptoms of a variety of disorders that involve the peripheral (otologic vertigo) and/or the central vestibular (brain-induced vertigo) systems. These produce asymmetric input into the central vestibular apparatus or asymmetrical central processing. If this process is acute, vertigo, nausea and vomiting may result. If it is more chronic, dizziness and/or disequilibrium may be the manifest symptoms.

Depending on their etiology, treatment options of vestibular disorders may be summarized as (Table 1):

  • Pharmacological treatments;
  • Liberatory and repositioning maneuver for BPPV treatment (specific maneuvers according to the location(s) of the otoconial debris; Epley and Semont maneuvers are common examples for repositioning debris located in the posterior semicircular canal);
  • Vestibular rehabilitation (e.g. exercises for eye and head stabilization, proprioceptive training or habituation exercises);
  • Psychotherapeutic measures (particularly important in psychogenic vertigo);
  • Surgical treatments – in less frequent lesions such as semicircular canal dehiscence, where there is a lack of bone covering one or more semicircular canals and ear tumors (e.g. vestibular schwannoma); some drugs (namely gentamicin and dexamethasone) may also be applied transtympanically as a simple procedure under topical anesthesia.

With this paper we aim to introduce the reader to the complexity of decision-making when treating vestibular disorders, as well as to analyze the most used pharmacologic strategies for the most common etiologies of vertigo and dizziness.

TABLE 1. VERTIGO AND DIZZINESS TREATMENT OPTIONS

Pharmacological

Liberatory and reposition maneuvers

Vestibular rehabilitation

Psychotherapeutic measures

Surgical treatments

PREREQUISITES FOR PHARMACOLOGICAL TREATMENT

While vestibular diagnosis has tremendously evolved with the development of new instruments – vHIT (video Head Impulse Test) and VEMP (vestibular evoked myogenic potentials), just to mention a few examples – the treatment of vestibular pathology has undergone many changes not so much by the discovery of new medications, but rather by the use of medications originally used for non-vestibular pathologies. Many of these drugs are still used in off-label manners (i.e., are used in a way not specified in the FDA’s approved label). This is because only a few medications have proven, in controlled trials, to be effective. As in all cases and particularly with these drugs, patients should therefore be informed before starting treatment of the balance between risks and benefits.

The prerequisites for successful pharmacological treatment of vertigo and dizziness are the “4 D’s”2: correct diagnosis, correct drug, appropriate dosage and sufficient duration (Table 2).

Table 2. Prerequisites for pharmacological treatment

Correct Diagnosis

Correct Drug

Appropriate Dosage

Sufficient Duration

The first step for successful treatment, establishing a diagnosis, is especially important because vertigo and dizziness are not diseases – they are symptoms: just as headaches, nausea or fever relate to specific pathologic conditions, so do vertigo and dizziness. Recording a patient’s clinical history should search for the clarification of these symptoms:

  • Is there vertigo or dizziness? With vertigo the patient will have a sensation of false or distorted self-motion.
  • Are the patient’s symptoms spontaneous or triggered (e.g., by head movement or position changes)?
  • How long has the patient had symptoms, and how often do they occur? When did symptoms first begin?
  • Are there accompanying symptoms, namely ear symptoms or neurological symptoms?

Clinical examination is also mandatory for diagnosis and should be carried out in every patient. Eye movement evaluation is one of the major windows in this respect because particular eye movements are evoked by particular vestibular conditions. A precise and brief neurological and otological examination should also be conducted.

Treatment is dictated by the patient’s diagnosis. The use of medication for the treatment of vestibular disorders may be directed to treat the etiology, control the symptoms, accelerate central compensation or diminish the psychological comorbidity that often accompanies the syndrome (Table 3).

Table 3. Medication targets in vertigo and dizziness

Treat the etiology

Control the symptoms

Accelerate central compensation

Diminish the psychological comorbidity

There are six major groups of drugs that can be used for to treat vertigo and dizziness (Table 4): antiemetics; anti-inflammatories, anti-Ménière’s, anti-migrainous; antidepressants and anticonvulsants

Table 4. Drug groups in vertigo and dizziness treatment

Anti-inflammatories

Anti-migrainous

Anticonvulsants

Anti-Ménière’s

Antidepressants

Antiemetics

PHYSIOLOGY

Vertigo is the illusion of rotational motion. Most vertigo with definable cause is otologic, caused by dysfunction of the labyrinth in the inner ear. Normal persons continuously process three types of sensory input: visual, vestibular (inner ear) and somatosensory (sense for position and movement of body parts) to estimate the orientation and motion of the head and body. Physiologic and pathologic vertigo is caused by asymmetric input into the central vestibular apparatus or asymmetrical central processing. Many pathways and neurotransmitters are involved in causing the vertigo and autonomic complaints. This explains why so many classes of drugs are used in the management of this disorder. Occasionally in some oculomotor disturbances accompanied by nystagmus (rhythmic and involuntary eye movement) the patient can feel oscillopsia: the illusion that the world is jumping or swinging back and forth. There are some medications to diminish this disabling symptom and improve the visual support (e.g. clonazepam for certain cerebellar induced nystagmus).

In addition to the symptom of vertigo, motion sickness (the malaise and nausea which may follow real or illusory sensations of motion) should also be considered. Vertigo and motion sickness are not synonymous. For example, reading in a moving car may, in susceptible persons, induce nausea and autonomic symptoms but not the false sensation of self-motion.

VERTIGO AND DIZZINESS PHARMACOLOGICAL APPROACH

Clinically, treatment options for patients with vertigo include symptomatic, specific and prophylactic approaches. Symptomatic treatment involves controlling the acute symptoms and autonomic complaints (e.g., vertigo and vomiting). Specific treatment involves targeting the underlying cause of the vertigo (e.g., ear infection). Prophylactic treatment aims to reduce the recurrence of specific vertiginous conditions, as in Ménière’s disease, migrainous vertigo or vestibular paroxysmia.

Symptomatic control: vestibular suppressants and antiemetics

Symptomatic control involves managing the acute symptoms and autonomic complaints (e.g., vertigo and vomiting). There is a connection between the part of the brain involved in vomiting and the vestibular system. If the vestibular system is strongly stimulated, either by real motion or by vertigo, the vomit center becomes active and nausea and vomiting occurs. Nausea and vomiting can be even more stressful than vertigo itself, therefore being one of the main targets for pharmacological treatment. Other associated symptoms named “autonomic symptoms” are pallor, swelling, salivation, diarrhea and abdominal distention.

Vestibular suppressants

Vestibular suppressants are drugs that reduce the intensity of vertigo and nystagmus evoked by a vestibular imbalance. These also reduce the associated motion sensitivity and motion sickness. Conventional vestibular suppressants consist of three major drug groups: anticholinergics, antihistamines and benzodiazepines.

Benzodiazepines

Diazepam (Valium®), clonazepam, lorazepam and alprazolam are benzodiazepines commonly prescribed for their effect as anxiolytics and antidepressants. These drugs also act as vestibular suppressants and can, in small dosages, be extremely useful for the management of acute vertigo3. They are also useful in controlling motion sickness4 and can also minimize anxiety and panic associated with vertigo. Habituation, impaired memory, increased risk of falling and vestibular compensation are potential side effects. Their use as vestibular suppressants should therefore be limited in time. Nevertheless, they should not be stopped suddenly because of potential withdrawal syndrome.

Antihistamines include meclizine (Antivert®), dimenhydrinate, diphenhydramine (Benadryl®) and promethazine. These drugs can prevent motion sickness and reduce the severity of symptoms even if taken after the onset of symptoms5. Dry mouth and blurry vision are side effects that result from their anticholinergic action.

Anticholinergics

Anticholinergics are vestibular suppressants that inhibit firing in vestibular nucleus neurons6 as well as reduce the velocity of vestibular nystagmus in humans. The most effective single anticholinergic drug for the prophylaxis and treatment of motion sickness is scopolamine. All anticholinergics conventionally used in the management of vertigo or motion sickness have prominent side effects, often including dry mouth, dilated pupils and sedation.

Antiemetics

Antiemetics are drugs that are commonly used to control vomiting and nausea. The choice for vertiginous patients depends upon the route of administration and the side effect profile. Injectables are mostly used in the emergency room or inpatient settings. Dexamethasone (Decadron®) and ondansetron (Zofran®) are powerful and well-established inpatient-setting antiemetics. While not FDA approved, droperidol (Droleptan®) is widely used outside the U.S. The oral agents are only used for mild nausea, with sublingual administration preferable for outpatients. When an oral agent is appropriate, meclizine or dimenhidrinate (Dramamine®), antihistamines commonly used also as vestibular suppressants, are generally the first to be used because they rarely cause adverse effects any more severe than drowsiness. Phenothiazines, such as prochlorperazine (Compazine) and promethazine (Phenameth®, Phenergan®), are also effective antiemetics but side effects include sedation and the possibility of extrapyramidal symptoms (dystonia and Parkinsonism). Drugs that speed gastric emptying, such as metoclopramide (Reglan®) and Domperidone may also be helpful in managing vomiting7.

TREATMENT OF INDIVIDUAL SELECTED CONDITIONS

Vestibular Neuritis

Vestibular neuritis is the most common cause for acute vestibular syndrome (acute vertigo with acute nystagmus). Although it is believed to be caused by the reactivation of a virus (Herpes simplex virus: type 1) in the vestibular nerve (vestibular neuritis), it does not benefit from antiviral treatment but rather from methylprednisolone (Medrol®), a corticosteriod. In fact, this drug alone has proven to significantly improve the recovery of peripheral vestibular function in patients with vestibular neuritis8.

Symptomatic treatment should also be provided in the first days (see section 2. Symptomatic control: vestibular suppressants and antiemetics). In the emergency room Dexamethasone, also a corticoid, may be particularly useful for both its anti-emetic and anti-inflammatory properties. Treatment with vestibular suppressors should be discontinued once the acute symptoms are controlled; chronic treatment with these drugs is discouraged to prevent the inadequate compensation. Vestibular rehabilitation has shown to be most effective strategy in reaching complete clinical recovery9.

Vestibular Migraine

This long-ignored condition is currently recognized as one of the most common causes for vertigo and dizziness. A number of criteria have to be addressed, but simplistically both migraine and vertigo or dizziness must be related in time in order to diagnose this condition. The treatment includes trigger avoidance, pharmacotherapy and vestibular rehabilitation. For acute attacks only symptomatic control is eventually effective (see section 2. Symptomatic control: vestibular suppressants and antiemetics) as migraine abortive agents such as triptans have reached inconclusive results. Prophylactic treatment protocols are based on the ones from migraine headache, and include β-blockers such as propranolol or metoprolol; calcium-channel blockers such as verapamil, antidepressants such as amitriptyline, fluoxetine, or venlafaxine10; anticonvulsants such as valproate or topiramate, and carbonic anhydrase inhibitors such as acetazolamide.

Ménière’s Disease

Ménière’s disease is the second most common cause of vertigo of otologic origin and is classically attributed to dilation and periodic rupture of the endolymphatic compartment of the inner ear. The pathognomonic symptoms include episodic vertigo, ipsilateral fluctuating hearing loss, aural fullness and tinnitus11. The treatment should therefore address these symptoms, i.e. stop vertigo attacks, abolish tinnitus and reverse or preserve the hearing loss. Clinically the pharmacological treatment is addressed at the acute episode management, prevention of new attacks and the treatment of audio-vestibular dysfunction. There is no consensus on prophylaxis of Ménière’s syndrome, with major differences between the U.S. and Europe regarding whether betahistine offers therapeutic benefits (see prevention of attack).

The treatment during the attack is symptomatic and similar to other etiologies of spontaneous vertigo, with vestibular suppressors and antiemetics being the most appropriated strategies.

Irrespective of the prophylactic treatment used, remission may eventually occur in 60% to 80% of cases12-13. At start, patients should follow dietary salt restriction (1-2 gram salt diet) and adequate hydration (35 ml/kg of liquids). Patients should also avoid caffeine and stop smoking. If the patient does not achieve a good control of symptoms by following this regimen, a mild diuretic, such as Dyazide® or Maxide® (hydrochlorothiazide-triamterene), may reduce the frequency of attacks14. It should be noted that diuretics may cause significant hyponatremia and low blood pressure, especially in the elderly and in those who are already on salt-restricted diets.

This treatment with betahistine regimen is widespread worldwide, with a survey in England reporting that 94% of ENT surgeons prescribe betahistine to their Ménière’s patients14. The underlying mode of action is believed to be through increased inner-ear blood flow, with local vasodilation and increased permeability, thereby relieving pressure from the inner ear. A long-term high-dose treatment with betahistine (at least 48 mg three times daily), has shown a significant effect on the frequency of the attacks15.

Some patients also respond well to corticoids. Studies on transtympanic steroids have shown evidence of good preservation of hearing and tinnitus control with substantial decrease in the number of vertigo spells16. Before considering nonconservative measures, using transtympanic steroids could be a good approach in patients refractory to betahistine, those with bilateral Ménière’s and those with relatively good hearing in the affected ear.

Patients with Ménière’s disease may become disabled by recurrent vertigo; in this situation surgical treatment to inactivate all or part of the labyrinth could correctly be indicated.

In recent years, Ménière’s treatment has been revolutionized by the use of transtympanic “low-dose gentamicin.” In 1997, Driscoll reported that a single dose of gentamicin through the eardrum eliminated recurrent vertigo in 84% of his patients17. This procedure has made it possible to control vertigo after other drug treatments have failed.

There is not much evidence that treatment of chronic audio-vestibular dysfunction prevents further progression of hearing loss. Hearing aids and vestibular rehabilitation could be indicated.

Vestibular paroxysmia – neurovascular cross-compression

Vestibular paroxysmia is believed to be caused by the neurovascular compression of the cochleovestibular nerve, as it occurs with other neurovascular compression syndromes (e.g. trigeminal neuralgia). The irregular and unpredictable spells are the most disabling aspect of this condition, making some daily activities, like driving, extremely dangerous. In theory, given its pathophysiology, surgical treatment could be considered. Still, due to the substantial surgical risks involved, this approach is reserved for particular cases where pharmacological treatment is not effective or tolerated. Treatment with carbamazepine (Tegretol®) or oxcarbamazepine (Trileptal®), both anticonvulsants primarily used in the treatment of epilepsy, is usually not only effective in small dosages, but is also diagnostic. Vestibular depressants are not effective.

CONCLUSIONS

Together with physical therapy and lifestyle changes, the pharmacological approach is one of the three pillars for vestibular disorder treatment. The use of medication in each case comes from a proper assessment of symptoms, severity of disease and side effects. Vestibular suppressants should only be used in acute cases to alleviate the stressful symptoms because prolonged use may generate a chronic vestibular imbalance. Preventive medications generally do not cure the underlying disease but may decrease or abolish the number of attacks of vertigo and dizziness. Most of the drugs used for vertigo treatment act specifically on certain receptors or ion channels, but there are several neurotransmitters and pathways involved in causing the vertigo and autonomic complaints. The knowledge of some of these pathways and drug mechanisms has enabled recent advances in the treatment of specific vestibular disorders, such as vestibular migraine, vestibular paroxysmia or some central nystagmus. Still, the main focus should be kept on establishing a correct diagnosis, then developing an effective treatment regime, for patients suffering from vertigo and dizziness.

Click here to download “Pharmacological Treatments for Vestibular Disorders.”

BIBLIOGRAPHY

Treatment of Vertigo

Treatment of Specific Disorders

BENIGN PAROXYSMAL POSITIONAL VERTIGO

Benign paroxysmal positional vertigo is caused by calcium debris in the semicircular canals (canalithiasis), usually the posterior canal. Medications generally are not recommended for the treatment of this condition.

The vertigo improves with head rotation maneuvers that displace free-moving calcium deposits back to the vestibule. Maneuvers include the canalith repositioning procedure or Epley maneuver15 and the modified Epley maneuver16 (Figure 2). The modified Epley maneuver can be performed at home.

Figure 2.

Epley maneuver. The patient sits on the examination table, with eyes open and head turned 45 degrees to the right (A). The physician supports the patient’s head as the patient lies back quickly from a sitting to supine position, ending with the head hanging 20 degrees off the end of the examination table (B). The physician turns the patient’s head 90 degrees to the left side. The patient remains in this position for 30 seconds (C). The physician turns the patient’s head an additional 90 degrees to the left while the patient rotates his or her body 90 degrees in the same direction. The patient remains in this position for 30 seconds (D). The patient sits up on the left side of the examination table. (E) The procedure may be repeated on either side until the patient experiences relief of symptoms.

Figure 2.

Epley maneuver. The patient sits on the examination table, with eyes open and head turned 45 degrees to the right (A). The physician supports the patient’s head as the patient lies back quickly from a sitting to supine position, ending with the head hanging 20 degrees off the end of the examination table (B). The physician turns the patient’s head 90 degrees to the left side. The patient remains in this position for 30 seconds (C). The physician turns the patient’s head an additional 90 degrees to the left while the patient rotates his or her body 90 degrees in the same direction. The patient remains in this position for 30 seconds (D). The patient sits up on the left side of the examination table. (E) The procedure may be repeated on either side until the patient experiences relief of symptoms.

Patients may need to remain upright for 24 hours after canalith repositioning to prevent calcium deposits from returning to the semicircular canals, although this measure is not universally recommended. Contraindications to canalith repositioning procedures include severe carotid stenosis, unstable heart disease, and severe neck disease, such as cervical spondylosis with myelopathy or advanced rheumatoid arthritis.17

Canalith repositioning has been found to be effective in patients with benign paroxysmal positional vertigo. The initial report15 on the Epley maneuver indicated an 80 percent success rate after a single treatment and a 100 percent success rate with repeated treatments. Two subsequent RCTs18,19 reported success rates of 50 to 90 percent. A Cochrane systematic review20 concluded that the Epley maneuver is a safe treatment that is likely to result in improvement of symptoms and conversion from a positive to negative Dix-Hallpike maneuver. However, the review20 noted that no long-term assessment was performed in either RCT18,19 on the use of the Epley maneuver. A study16 of 54 patients with benign paroxysmal positional vertigo found that the modified Epley maneuver was effective in resolving vertigo symptoms after one week of treatment. This study, however, has been criticized for inadequate randomization and lack of blinding of outcome assessors (patient self-report of symptoms).20

One study21 on the long-term effects of canalith repositioning procedures in patients with benign paroxysmal positional vertigo reported a recurrence rate of about 15 percent per year. Another study22 reported recurrence rates of 20 percent at 20 months and 37 percent at 60 months.

VESTIBULAR NEURONITIS AND LABYRINTHITIS

Acute inflammation of the vestibular nerve is a common cause of acute, prolonged vertigo. Associated hearing loss occurs if the labyrinth is involved. The vertigo usually lasts a few days and resolves within several weeks. Many cases of vestibular neuronitis or labyrinthitis are attributed to self-limited viral infections,7 although specific proof of a viral etiology rarely is identified.1

Treatment focuses on symptom relief using vestibular suppressant medications,6–8 followed by vestibular exercises.14 Vestibular compensation occurs more rapidly and more completely if the patient begins twice-daily vestibular rehabilitation exercises as soon as tolerated after the acute vertigo has been alleviated with medications.7,11

MÉNIÈRE’S DISEASE

Ménière’s disease (or endolymphatic hydrops) presents with vertigo, tinnitus (low tone, roaring, or blowing quality), fluctuating low-frequency sensorineural hearing loss, and a sense of fullness in the ear. In this disorder, impaired endolymphatic filtration and excretion in the inner ear leads to distention of the endolymphatic compartment.

Treatment lowers endolymphatic pressure. Although a low-salt diet (less than 1 to 2 g of salt per day) and diuretics (most commonly the combination of hydrochlorothiazide and triamterene ) often reduce the vertigo, these measures are less effective in treating hearing loss and tinnitus.23,24 Note, however, that the authors of a systematic review25 of treatments for Ménière’s disease criticized the statistical analysis of the frequency of vertigo episodes in one of the studies.23

In rare cases, surgical intervention, such as decompression with an endolymphatic shunt or cochleosacculotomy, may be required when Ménière’s disease is resistant to treatment with diet and diuretics. Ablation of the vestibular hair cells with intratympanic injection of gentamicin also may be effective.26 Surgery usually is reserved for patients with severe, refractory Ménière’s disease.

VASCULAR ISCHEMIA

The sudden onset of vertigo in a patient with additional neurologic symptoms (e.g., diplopia, dysarthria, dysphagia, ataxia, weakness) suggests the presence of vascular ischemia.

Treatment of transient ischemic attack and stroke includes preventing future events through blood pressure control, cholesterol-level lowering, smoking cessation, inhibition of platelet function (e.g., aspirin, clopidogrel , aspirin-dipyridamole ) and, possibly, anticoagulation (warfarin ).

Acute vertigo caused by a cerebellar or brainstem stroke is treated with vestibular suppressant medication and minimal head movement for the first day. As soon as tolerated, medication should be tapered, and vestibular rehabilitation exercises should be initiated.8,10

Placement of vertebrobasilar stents may be considered in a patient with symptomatic critical vertebral artery stenosis that is refractory to medical management.27 Rarely, infarction or hemorrhage in the cerebellum or brainstem may present with acute vertigo as the only neurologic symptom.28 Given the risk of brainstem compression with a large cerebellar stroke, neurosurgical decompression may be indicated.

MIGRAINE HEADACHES

Epidemiologic evidence shows a strong association between vertigo and migraine.29 Diagnostic criteria have been proposed to provide a more specific definition of vertiginous migraine.29 Diagnostic accuracy is important because vertiginous migraine may respond better to migraine treatments than to other interventions.

One retrospective review30 found that migraine treatments were effective in about 90 percent of patients with migraine-associated vertigo. Treatments included dietary changes (i.e., reduction or elimination of aspartame, chocolate, caffeine, or alcohol), lifestyle changes (i.e., exercise, stress reduction, improvements in sleep patterns), vestibular rehabilitation exercises, and medications (e.g., benzodiazepines, tricyclic antidepressants, beta blockers, selective serotonin reuptake inhibitors , calcium channel blockers, antiemetics).

Another retrospective chart review31 demonstrated that stepwise treatment of migraine-associated dizziness (vertigo or dysequilibrium) resulted in complete or dramatic reduction of symptoms in 58 of 81 patients (72 percent). The stepwise treatment consisted of initiating dietary changes, then adding nortriptyline (Pamelor) if needed, then adding atenolol or a calcium channel blocker if needed and, finally, consultation with a neurologist if needed.

A survey32 of 53 patients with migraine at a university-based headache clinic found that the efficacy of medications in treating migraine-associated dizziness was directly correlated with their ability to alleviate migraines. This correlation was strongest in patients with vertigo who were receiving migraine-abortive medications (most significantly, sumatriptan ).

PSYCHIATRIC DISORDERS

Vertigo commonly is associated with anxiety disorders (e.g., panic disorder, generalized anxiety disorder) and, less frequently, depression.33,34 Hyperventilation usually occurs and can result in hypocapnia with reversible cerebral vasoconstriction. Hyperventilation and hypocapnia may be accompanied by dyspnea, chest pain, palpitations, or paresthesias.

Subclinical vestibular dysfunction has been measured in patients with anxiety disorders or depression, most commonly panic disorder with moderate to severe agoraphobia.33 Conversely, classic vertigo resulting from more ostensible vestibular pathology usually induces severe anxiety symptoms and thus can be hard to distinguish from a primary anxiety disorder.

Vestibular suppressants and benzodiazepines most frequently are used to treat dizziness that is associated with anxiety disorder, but these medications provide only transient or inadequate relief.34 SSRIs such as citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) may provide better relief.

A review34 of 68 patients from a research database at a university neurotology center evaluated open-label SSRI treatment of dizziness associated with psychiatric symptoms (with or without neurotologic illness). Significant improvement of dizziness occurred in 38 patients (63 percent); however, 15 (25 percent) of the 60 patients experienced intolerable side effects. Because some side effects of SSRIs (e.g., nausea, sedation, dizziness) may be more intolerable for patients who have dizziness in association with psychiatric symptoms, slow titration should be used.34

Other medications that are effective in patients with anxiety disorders or depression, such as norepinephrine-serotonin reuptake inhibitors (e.g., venlafaxine ) and tricyclic antidepressants (e.g., nortriptyline, desipramine ), have not been evaluated in patients with concomitant vertigo.

Nonpharmacologic treatments for anxiety disorders, such as cognitive behavior therapy, may be helpful. A small prospective RCT of vestibular rehabilitation combined with cognitive behavior therapy to reduce anxiety in older patients with dizziness showed that this combination of treatments improved gait speed and dizziness symptoms but did not improve anxiety or depression.35

PHYSIOLOGIC VERTIGO

Motion sickness9 is attributed to an incongruence in the sensory input from the vestibular, visual, and somato-sensory systems. Motion sickness occurs while riding in a car, boat, or airplane if the vestibular and somato-sensory systems sense movement, but the visual system does not.

On the first sensation of motion sickness, efforts should be made to bring vestibular, visual, and somato-sensory input back in congruence. For example, a person on a boat who starts to feel seasick should immediately watch the horizon. Seasickness can be prevented by applying a scopolamine patch (Transderm-Scop) behind one ear at least four hours before boating.8,36

Dimenhydrinate

Before taking dimenhydrinate,

  • talk with your doctor and pharmacist if you are allergic to dimenhydrinate, any other medications, or any of the ingredients in the dimenhydrinate preparation. If you are taking dimenhydrinate chewable tablets, talk to your doctor if you are allergic to tartrazine (FD&C Yellow No. 5, a color additive) or aspirin. Ask your doctor or pharmacist or check the package label for a list of the ingredients.
  • talk with your doctor and pharmacist about what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Be sure to mention any of the following: aminoglycoside antibiotics such as such as amikacin (Amikin), gentamicin (Garamycin), kanamycin (Kantrex), neomycin (Neo-Rx, Neo-Fradin), netilmicin (Netromycin), paromomycin (Humatin), streptomycin, and tobramycin (Tobi, Nebcin); antidepressants such as amitriptyline (Elavil), amoxapine (Asendin), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Adapin, Sinequan), imipramine (Tofranil), nortriptyline (Aventyl, Pamelor), protriptyline (Vivactil), and trimipramine (Surmontil); antihistamines, such as diphenhydramine; cough and cold medications; ipratropium (Atrovent); medications for anxiety, irritable bowel disease, mental illness, Parkinson’s disease, seizures, ulcers, or urinary problems; narcotic or strong pain relievers or muscle relaxants; sedatives; sleeping pills; and tranquilizers. Your doctor may need to change the doses of your medications or monitor you carefully for side effects.
  • talk with your doctor if you have or have ever had asthma; shortness of breath or difficulty breathing, including chronic bronchitis (swelling of the air passages that lead to the lungs) or emphysema (damage to air sacs in the lungs); difficulty urinating due to enlargement of the prostate (male reproductive organ); glaucoma (an eye disease that can cause vision loss); or seizures.
  • talk with your doctor if you are pregnant, plan to become pregnant, or are breast-feeding. If you become pregnant while taking dimenhydrinate, call your doctor.
  • if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking dimenhydrinate.
  • you should know that dimenhydrinate may make you drowsy. Do not drive a car, operate machinery, or participate in potentially dangerous activities until you know how this medication affects you.
  • avoid alcoholic beverages or products containing alcohol while taking dimenhydrinate. Alcohol can make the side effects from dimenhydrinate worse.
  • if you have phenylketonuria (PKU, an inherited condition in which a special diet must be followed to prevent mental retardation), read the package label carefully before taking dimenhydrinate. Dimenhydrinate chewable tablets contain aspartame that forms phenylalanine.
  • talk to your doctor about the risks and benefits of taking dimenhydrinate if you are 65 years of age or older. Older adults should not usually take dimenhydrinate because it is not as safe or effective as other medications that can be used to treat the same condition.

HOME TREATMENTS OF BENIGN PAROXYSMAL POSITIONAL VERTIGO

(BPPV)

Timothy C. Hain, MD Page last modified: January 30, 2019

These maneuvers are all for the most common type of BPPV, the “PC” or posterior canal variety. There are also home treatments for the rarer types of BPPV, but usually it is best to go to a health care provider for these as they are trickier. If you just want to “.

Introduction

There are many methods of treating BPPV at home. These have many advantages over seeing a doctor, getting diagnosed, and then treated based on a rational procedure of diagnosis– The home maneuvers are quick, they often work, and they are free.

There are several problems with the “do it yourself” method.

  • If the diagnosis of BPPV has not been confirmed, one may be attempting to treat another condition (such as a brain tumor or stroke) with positional exercises — this is unlikely to be successful and may delay proper treatment.
  • A second problem is that the most home maneuvers requires knowledge of the “bad” side. Sometimes this can be tricky to establish.
  • Complications such as conversion to another canal, or severe vomiting can occur during the Epley maneuver, which are better handled in a doctor’s office than at home.
  • Finally, occasionally during the Epley maneuver neurological symptoms are provoked due to compression of the vertebral arteries.

In our opinion, it is safer to have the first Epley performed in a doctors office where appropriate action can be taken in this eventuality.

That being said, here is the list of home maneuvers, ordered by our opinion as to which one is the best:

  • Home-Epley
  • Home-Semont
  • Foster -half sumersault
  • Brandt-Daroff
  • full-circle

BRANDT-DAROFF EXERCISES (The first home treatment described for PC BPPV, but not the best)

The Brandt-Daroff Exercises are a home method of treating BPPV, usually used when the side of BPPV is unclear. It was proposed many years ago, when we didn’t understand the mechanism of BPPV (Brandt and Daroff, 1980). Their use has been declining in recent years, as the home Epley maneuver (see below) is considerably more effective. They succeed in 95% of cases but are more arduous than the office treatments. We occasionally still suggest them for patients with atypical BPPV.

These exercises also may take longer than the other maneuvers — the response rate at one week is only about 25% (Radke et al, 1999). These exercises are performed in three sets per day for two weeks. In each set, one performs the maneuver as shown on the right five times.

1 repetition = maneuver done to each side in turn (takes 2 minutes)

Suggested Schedule for Brandt-Daroff exercises
Time Exercise Duration
Morning 5 repetitions 10 minutes
Noon 5 repetitions 10 minutes
Evening 5 repetitions 10 minutes

Start sitting upright (position 1). Then move into the side-lying position (position 2), with the head angled upward about halfway. An easy way to remember this is to imagine someone standing about 6 feet in front of you, and just keep looking at their head at all times. Stay in the side-lying position for 30 seconds, or until the dizziness subsides if this is longer, then go back to the sitting position (position 3). Stay there for 30 seconds, and then go to the opposite side (position 4) and follow the same routine.

These exercises should be performed for two weeks, three times per day, or for three weeks, twice per day. This adds up to 42 sets in total. In most persons, complete relief from symptoms is obtained after 30 sets, or about 10 days. In approximately 30 percent of patients, BPPV will recur within one year. Unfortunately, daily exercises are not effective in preventing recurrence (Helminski and Hain, 2008). The Brandt-Daroff exercises as well as the Semont and Epley maneuvers are compared in an article by Brandt (1994), listed in the reference section.

When performing the Brandt-Daroff maneuver, caution is advised should neurological symptoms (i.e. weakness, numbness, visual changes other than vertigo) occur. Occasionally such symptoms are caused by compression of the vertebral arteries (Sakaguchi et al, 2003). In this situation we advise not proceeding with the exercises and consulting ones physician. It is also best to stop if one develops neck pain.

Multicanal BPPV (usually mild) often is a consequence of using the Brandt-Daroff exercises. This is probably because one does it over and over, and because the geometry is not very efficient. Lots of opportunities for rocks to go into the wrong place.

Other resources:

  • Animation of Brandt-Daroff exercises. Note that this treatment maneuver is done faster in the animation than in actual use. Usually one allows 30 seconds between positions.

HOME EPLEY MANEUVER (the best home treatment maneuver)

The Epley and/or Semont maneuvers can be done at home (Radke et al, 1999; Radke et al, 2004; Furman and Hain, 2004). We often recommend the home-Epley to our patients who have a clear diagnosis. This procedure seems to be even more effective than the in-office procedure, perhaps because it is repeated every night for a week. At this writing (2015) there are many home maneuvers. As there is only one way to move things around in a circle, they all boil down to the same head positions – -just different ways of getting there. The Epley maneuver is the best established.

The home Epley method (for the left side) is performed as shown on the figure to the right. The maneuver for the right side is just the mirror image.

One stays in each of the supine (lying down) positions for 30 seconds, and in the sitting upright position (top) for 1 minute. Thus, once cycle takes 2 1/2 minutes. Typically 3 cycles are performed just prior to going to sleep. It is best to do them at night rather than in the morning or midday, as if one becomes dizzy following the exercises, then it can resolve while one is sleeping.

HOME SEMONT MANEUVER (middle efficacy)

Radke et al (2004) also studied the home Semont maneuver, using a similar procedure as the home-Epley. They reported that the home-Semont was not as effective as the home-Epley, because it was too difficult to learn. The difference was quite remarkable: 95% for the Epley vs. 58% for the Semont. As the positions of the head are almost identical to the home-Epley, it should be equivalent. While we occasionally suggest it to patients, this is not one to learn from a web-page.

The “Foster” or half somersault maneuver. While it is on Youtube, the home Epley is better.

In 2012, Dr. Carol Foster reported another self-treatment maneuver for posterior canal BPPV, that she subsequently popularized with an online video on youtube. In this maneuver, using the illustrations above that she published in her 2012 article, one begins with head up, then flips to upside down, comes back up into a push-up position with the head turned laterally (actually 45 deg), and then back to sitting upright. Biomechanically, this is another way to get a series of positions similar to the Epley maneuver. The trick of it is that instead of putting the head far backward (as in the Epley), one puts the head very far forward.

The illustrations above are not very accurate in showing the positions (as described in the text of the article), or showing the position of the canals in the ear. In particular, position D makes it look as if the head should be turned 90 degrees on the trunk, but the article says turn the head 45 degrees on the trunk. This would be reasonable, but 90 degrees would not.

The Foster maneuver appears to require a bit more strength and flexibility to perform than the self-Epley maneuver reported by Radke (1999), or for that matter, nearly any of the other maneuvers. Of course, it doesn’t really matter how you get your head into these positions – -as they all do the same thing. Other problems might be insufficient flexibilty to attain position A (with the head far back), or danger of falling over when one is dizzy in positions B-E. We have no idea how the Foster maneuver could prevent repeat bouts of BPPV — as it was our understanding that this was just the natural history of BPPV (more rocks falling off). We just don’t see how the Foster maneuver would stop this.

One might wonder if the Foster maneuver, which looks pretty close to the head-forward maneuver for anterior canal BPPV, might not also treat anterior canal BPPV. While we will not go into this much, the answer is no, the head is in the wrong place during position D.

Dr. Foster, in her published article (2012), stated that her half-sumersault maneuver is not as effective as the regular Epley maneuver, but patients prefer it anyway. Although it looks like a good arm workout, we don’t see any particular reason to use or not use Dr. Foster’s maneuver over any of the other recent home treatment BPPV maneuvers (i.e. home Epley, home Semont), as they all put the ear through very similar positions.

A Modest Proposal — Another maneuver anyone ?

There seems to be considerable willingness in the literature to propose new maneuvers, often named after their inventor, that are simple variants of older maneuvers. Well — there are still a few maneuvers left to adapt (:

If one is willing to engage in athletic positions as in the half-somersault procedure, why not just take things to the logical extreme and do a complete backward sumersault in the plane of the affected canal, starting from upright (A below), then to the home-Epley bottom position above (B below), then into the Foster position C — midway between B and C below, and then follow through to position C below (which is also position D of the Foster and home Epley), and then finally to upright again. Stopping for 30 seconds in each position. A full circle. This is a home version of the Lembert 360 rotation described in 1997.

I propose naming it “The full circle maneuver”. Or maybe the full backwards sumersault. We do not recommend that people try this maneuver out — as there are some practical issues (i.e. getting from position B to C) and we would not want anyone to hurt themselves. But it should work just as well as the others, as the positions of the head are the same. And thats the only thing that matters when one considers the efficiency of these maneuvers.

Illustration of the 360 rotation of the left posterior semicircular canal, From Lempert et al, 1997.

Vertigo

Medically reviewed by Drugs.com. Last updated on Jun 6, 2019.

  • Health Guide
  • Disease Reference
  • Care Notes
  • Medication List
  • Q & A

What Is It?

Vertigo is the sensation that either your body or your environment is moving (usually spinning). Vertigo can be a symptom of many different illnesses and disorders. The most common causes of vertigo are illnesses that affect the inner ear, including:

  • Benign paroxysmal positional vertigo — In this condition, a change in head position causes a sudden sensation of spinning. The most likely cause is small crystals that break loose in the canals of the inner ear and touch the sensitive nerve endings inside.

  • Acute labyrinthitis, also called vestibular neuritis — This is an inflammation of the balance apparatus of the inner ear, probably caused by a viral infection.

  • Ménière’s disease — This causes repeat episodes of dizziness, usually with ringing in the ear and progressive low-frequency hearing loss. Ménière’s disease is caused by a change in the volume of fluid inside the inner ear. Although the reason for this change is unknown, scientists suspect that it may be linked to loud noise, to a viral infection or to biologic factors inside the ear itself.

Symptoms

Vertigo can feel like the room is spinning or like you are spinning in the room, or it can be just a sense of imbalance. It may be associated with nausea, vomiting and ringing in one or both ears (tinnitus).

Diagnosis

Your doctor will diagnose vertigo based on your description of what you are feeling. Vertigo can be divided into two major categories, peripheral vertigo and central vertigo.

Peripheral vertigo, which is much more common, includes benign positional vertigo, labyrinthitis and Ménière’s disease. Positional vertigo is diagnosed when moving the head causes the vertigo and returning the head to a neutral position relieves symptoms. Labyrinthitis and Ménière’s attacks usually come on abruptly and last from a few hours to a couple of days. There may be intense nausea and vomiting and variable hearing loss.

Central vertigo is a more serious problem in the cerebellum (back part of the brain) or brain stem.

Your doctor will evaluate your eye to look for abnormal jerking movements (nystagmus). The pattern of your eye movements may help to determine if the problem is peripheral or central. Usually, no further testing is needed unless your doctor suspects you have central vertigo. If central vertigo is suspected, your doctor will order a computed tomography (CT) scan or magnetic resonance imaging (MRI) of your brain.

Expected Duration

Depending on its cause, vertigo may last only a few seconds or last for weeks or months.

Prevention

Vertigo can happen to anyone, and there is no way to prevent the first episode. Because vertigo can be associated with an intense sense of imbalance, it is important to avoid situations in which a fall could cause significant harm, like climbing a ladder or working on a slanted roof.

Treatment

Your doctor may begin treatment by recommending bed rest or prescribing medications that suppress the activity of the inner ear, such as meclizine (Antivert, Bonine and other brand names), dimenhydrinate (Dramamine) or promethazine (Phenergan); anticholinergic medications such as scopolamine (Transderm-Sco); or a tranquilizer, such as diazepam (Valium). Depending on the cause and duration of the vertigo, additional advice may be offered.

For benign paroxysmal positional vertigo, your doctor may move your head and body through a series of positions. This is done in the office, usually on the examining table. The maneuvers move the tiny free floating crystals out of the sensing tube. The most commonly used method is the Epley maneuver. Your doctor also may provide specific maneuvers for you to continue at home.

For more persistent vertigo, your doctor may recommend other types of vestibular rehabilitation, also called balance rehabilitation. The types of exercises prescribed depend upon the underlying cause of dizziness and what movements provoke the symptoms. Your doctor may refer you to an audiologist and/or a physical therapist to help design and instruct your therapy.

When To Call a Professional

Call your doctor if you have a new episode of vertigo, especially if it is associated with headache and significant coordination problems. Also call if you have mild vertigo that persists after a couple days.

Prognosis

Most cases of vertigo last a few hours to a few days. Symptoms caused by acute labyrinthitis almost always go away without permanent injury. Other causes of vertigo may result in symptoms that are more persistent.

Learn more about Vertigo

Associated drugs

  • Vertigo

IBM Watson Micromedex

  • Dizziness
  • Vertigo

Mayo Clinic Reference

  • Dizziness

External resources

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Medical Disclaimer

What are the home remedies for vertigo?

Vertigo can be managed naturally with a variety of home remedies.

Epley maneuver

Share on PinterestThe Epley maneuver is often recommended by chiropractors or physical therapists as a way of treating vertigo at home.

One of the most common ways to manage vertigo is a technique called the Epley maneuver. This involves a set of steps done before bed each night until the symptoms of vertigo resolve for at least 24 hours.

A report from the Institute for Quality and Efficiency in Health Care says 52 out of every 100 people who use the Epley maneuver gain relief from vertigo symptoms.

If symptoms of vertigo occur from the left side and left ear, the Epley maneuver can be done by:

  • sitting on the edge of a bed and turning the head 45 degrees to the left
  • lying down quickly and facing head up on the bed at a 45-degree angle
  • maintaining the position for 30 seconds
  • turning the head halfway — 90 degrees — to the right without raising it for 30 seconds
  • turning the head and entire body to the right side, looking downward for 30 seconds
  • slowly sitting up but remaining sitting for at least a few minutes

If vertigo starts on the right side in the right ear, these directions should be done in reverse.

Ginkgo biloba

Ginkgo biloba is a Chinese herb known for resolving the symptoms of vertigo. It works by managing blood flow to the brain to relieve dizziness and balance issues.

A study reported in the International Journal of Otolaryngology finds Ginkgo biloba is just as effective as the medication betahistine in managing vertigo.

Ginger tea

Research published in the Journal of Acupuncture and Tuina Science finds ginger root can reduce the effects of vertigo better than manual repositioning, such as the Epley maneuver, alone.

Ginger root can be steeped in a cup of boiling water for 5 minutes. Honey can help with the bitter taste. Drinking ginger tea twice a day may help dizziness, nausea, and other vertigo symptoms.

Almonds

Almonds are rich sources of vitamins A, B, and E. Eating a daily handful of almonds can help with vertigo symptoms.

How almonds help is unknown, but it is possible the vitamin content can combat the causes of vertigo.

Staying hydrated

Dehydration can cause symptoms of vertigo. Even mild dehydration can trigger the condition.

Staying hydrated can help minimize dizziness and balance issues.

The body needs 8 to 12 cups of liquid per day. While this includes all liquids, water is the best option because it is calorie- and caffeine-free and not a diuretic. Diuretics increase the amount of water and salt the body expels as urine.

Essential oils

Share on PinterestVarious essential oils, when applied topically or inhaled, may help to ease the symptoms of vertigo.

Essential oils are natural and affordable options for managing the symptoms of vertigo, including nausea, headaches, and dizziness.

Some of the options available for managing vertigo include peppermint, ginger, lavender, and lemon essential oils.

Essential oils are inhaled through an infuser or diluted in a carrier oil before being applied topically. A person may have to experiment with a variety of oils to find the best one to treat their vertigo symptoms.

Apple cider vinegar and honey

Both apple cider vinegar and honey are believed to have curative properties to relieve blood flow to the brain. Two parts honey and one part apple cider vinegar can prevent and treat vertigo symptoms.

Acupressure

Acupressure applies the same concepts as acupuncture, but it is without the needles. The goal of acupressure is to promote wellness and relaxation. It can help manage vertigo by stimulating pressure points throughout the body.

One common method, called the P6 acupressure method, involves an effective pressure point located in the two tendons between the inner forearm and the wrist.

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