eMedicine Specialties > Neurology > Neuro-otology

Benign Positional Vertigo: Treatment & Medication

Author: John C Li, MD, Private Practice in Otology and Neurotology; Medical Director, Balance Center
Contributor Information and Disclosures

Updated: Apr 27, 2009

Treatment

Medical Care

Treatment options include the following:

• Watchful waiting
  • Since benign paroxysmal positional vertigo is benign and can resolve on its own in weeks to months, the argument has been made that simple observation is all that is needed. On the other hand, this involves weeks or months of discomfort and vertigo, with the danger of falls and other accidents or injuries that may arise out of the episodic vertigo spells.
  • Vestibulosuppressant medications usually do not stop the vertigo. In some cases, they may provide minimal relief; however, they do not solve the problem but only mask it. To complicate matters, they may cause grogginess and sleepiness.
• Vestibular rehabilitation is a noninvasive therapy that can achieve success after lengthy periods of time. Unfortunately, it causes repeated stimulation of vertigo while performing the therapeutic maneuvers.
• Particle repositioning techniques are represented by 2 major variations that developed simultaneously, yet independently, in the United States and France. These variations are the "Epley Method" and the "Semont Method." Both involve movements of the head to rearrange displaced particles. The Semont maneuver involves rapid and vigorous side-to-side head and body movements. The Epley maneuver is more gentle, involving a reclining movement, and is described below. The author favors the Epley maneuver because it seems less violent and more physiologically sensible with respect to the presumed canalithiasis etiology.
• Recently, research has been conducted on multiaxial positioning devices that can perform canalith repositioning using 360-degree rotation in the proper plane of the semicircular canals.⁴ These automated repositioning chairs can help isolate the problematic semicircular canal, and they can help treat that particular canal without tremendous effect on the other canals. Furthermore, patients are securely fastened to the seats; therefore, they can be rotated more easily and can achieve the appropriate repositioning points better.
• The canalith repositioning procedure^5,6,7,8 is a simple, noninvasive, office treatment that is designed to actually cure benign paroxysmal positional vertigo in 1-2 sessions (see Media files 1-3). This therapy has enjoyed a success rate greater than 97% for patients with benign paroxysmal positional vertigo.^9,2 The procedure is conducted as follows:
  • Starting position: Patient is sitting, head turned 45 degrees toward the ipsilateral side.
    • The patient begins the procedure in a sitting position. The head is turned toward the affected side.
    • A mastoid bone oscillator is applied and held in position behind the affected ear by a headband to help agitate the particles so that they can move more easily.
  • Position 1: Patient is supine, head turned 45 degrees toward the ipsilateral side.
    • The patient is reclined slowly to the supine position of the affected side.
    • The rate is titrated to the point of no nystagmus and no symptoms. This usually takes about 30 seconds.
  • Position 2: Patient is supine, 15 degrees Trendelenburg, head turned 45 degrees toward the ipsilateral side.
    • The patient is reclined further to the Dix-Hallpike position of the affected side. This usually takes 10 seconds longer.
    • Another 20 seconds are spent in that Dix-Hallpike position (affected ear down).
  • Position 3: Patient is supine, 15 degrees Trendelenburg, head turned 45 degrees toward the contralateral side.
    • The patient's head is turned slowly from position 3 toward the opposite side.
  • Position 4: Patient is lying on the side with the contralateral shoulder down, head turned 45 degrees below the horizon toward the contralateral side.
    • The body is rolled so that the shoulders are aligned perpendicular to the floor (ie, affected ear up).
    • The head is turned further so that the nose points 45 degrees below the plane of the horizon. This usually takes another 40 seconds.
  • Position 5: Patient is sitting, head turned at least 90-135 degrees toward the contralateral side.
    • The patient is raised back to the sitting position with the head turned away from the affected side.
  • Position 6: Finally, the head is turned back to the midline. The mastoid bone oscillator is turned off and the headband is removed.
  • Dix-Hallpike test is done immediately following the procedure. If nystagmus is seen, the procedure is repeated.
  • After the procedure, the patient is instructed to avoid agitation of the head for about 48 hours while the particles settle, and to return within a week for follow-up examination.

Surgical Care

• Surgery usually is reserved for those in whom canalith repositioning procedure is not successful.
• Surgery is not the first line of treatment because it is invasive and carries the possibility of complications (eg, hearing loss, facial nerve damage).
• The options, all of which have a high chance of vertigo control, include the following:
  • Labyrinthectomy
  • Posterior canal occlusion
  • Vestibular nerve section
  • Singular neurectomy (ie, selective denervation of the posterior semicircular canal, sparing the other parts of the ear)
• Of all of these options, the posterior semicircular canal occlusion seems to be gaining the most favor. This procedure has the capability of hearing preservation, without sacrifice of the entire vestibular system. Only the affected posterior semicircular canal (or horizontal semicircular canal) is ablated. The other semicircular canals, as well as the saccule and utricle, are left intact. This procedure is far easier to perform than the singular neurectomy. Ongoing studies are evaluating its effects. Some have reported 95% improvement.

Consultations

Otolaryngological consultation should be considered for differentiating the associated inner ear disorders.

Activity

• After treatment, patients are instructed to avoid lying down completely flat for 24-48 hours. Sleeping with the head elevated on a few pillows is recommended.
• Avoidance of jarring activities or gymnastic flips is recommended.

Medication

Generally, medications are not recommended, as they do not seem to help. Supportive medications for vertigo include vestibulosuppressants and antiemetics. Several medications have antivertiginous properties (eg, meclizine, scopolamine, ephedrine, dimenhydrinate, diazepam) and others are useful as antiemetics (eg, promethazine, prochlorperazine). The majority of acute episodes are short-lived and self-limited.

Antihistamines

These agents prevent the histamine response in sensory nerve endings and blood vessels. They are effective in treating vertigo.

Meclizine (Antivert, Antrizine, Meni-D)

Decreases excitability of middle ear labyrinth and blocks conduction in middle ear vestibular-cerebellar pathways. These effects are associated with therapeutic effects in relief of nausea and vomiting.

Dimenhydrinate (Dimetabs, Dramamine)

A 1:1 salt of 8 chlorotheophylline and diphenhydramine thought to be useful in treatment of vertigo. Diminishes vestibular stimulation and depresses labyrinthine function through central anticholinergic effects. However, prolonged treatment may decrease rate of recovery of vestibular injuries.

Anticholinergics

These agents work centrally by suppressing conduction in the vestibular cerebellar pathways.

Scopolamine (Isopto)

Blocks action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and CNS. Antagonizes histamine and serotonin action.
Transdermal scopolamine may be most effective agent for motion sickness. Its use in vestibular neuronitis is limited by its slow onset of action.

Benzodiazepines

By binding to specific receptor sites, these agents appear to potentiate the effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters. These effects may prevent vertigo and emesis.

Diazepam (Valium)

Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA. Individualize dosage and increase cautiously to avoid adverse effects.

Phenothiazines

These agents are effective in treating emesis, possibly owing to effects in the dopaminergic mesolimbic system.

Promethazine (Phenergan)

Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.

Prochlorperazine (Compazine)

May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors, through anticholinergic effects, and by depressing reticular activating system.

Monoaminergics

These agents may relieve vertigo, possibly through modulating the sympathetic system.

Ephedrine (Pretz-D)

Stimulates release of epinephrine stores, producing alpha- and beta-adrenergic receptors.

• Search for CME/CE on This Topic »

• Benign Positional Vertigo (Emergency Medicine)
• Perilymph Fistula (Emergency Medicine)
• Benign Paroxysmal Positional Vertigo (Otolaryngology and Facial Plastic Surgery)

• Brain and Nervous System Center
• Benign Positional Vertigo Overview
• Benign Positional Vertigo Causes
• Benign Positional Vertigo Symptoms
• Benign Positional Vertigo Treatment
• Vertigo Overview

• The Challenges of Managing Vestibular Disorders: A Qualitative Study of Clinicians' Experiences Associated with Low Referral Rates for Vestibular Rehabilitation