A wide variety of medications are used to treat vertigo and the frequently concurrent nausea and emesis. These medications exhibit various combinations of acetylcholine, dopamine, and histamine receptor antagonism. The American Gastroenterological Association recommends anticholinergics and antihistamines for the treatment of nausea associated with vertigo or motion sickness. Gamma-aminobutyric acid GABA is an inhibitory neurotransmitter in the vestibular system.
Older patients are at particular risk for side effects of vestibular suppressant medications e. These patients also are more likely to experience drug interactions i. Vestibular rehabilitation exercises commonly are included in the treatment of vertigo 9 , 10 see patient information handout. These exercises train the brain to use alternative visual and proprioceptive cues to maintain balance and gait. It is necessary for a patient to reexperience vertigo so that the brain can adapt to a new baseline of vestibular function.
A randomized, controlled trial RCT 11 of primary care patients with dizziness and vertigo showed that vestibular rehabilitation exercises improved nystagmus, postural control, movement-provoked dizziness, and subjective indexes of symptoms and distress. Another RCT 12 evaluated the effectiveness of home vestibular rehabilitation in patients with chronic vertigo with a peripheral vestibular etiology.
This trial 12 showed a significant reduction of vertigo and an increase in the ability to perform activities of daily living independently. A retrospective case series 13 assessed the efficacy of physical therapy in patients who had vestibular and balance disorders with or without a history of migraine. Both groups showed significant alleviation of dizziness and improvement of balance and gait. Vestibular exercises also have been shown to improve postural control during the first month after acute unilateral vestibular lesions resulting from vestibular neuronitis.
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.
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Maneuvers include the canalith repositioning procedure or Epley maneuver 15 and the modified Epley maneuver 16 Figure 2. The modified Epley maneuver can be performed at home. Epley maneuver. The patient sits on the examination table, with eyes open and head turned 45 degrees to the right A. The patient remains in this position for 30 seconds C. 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.
Canalith repositioning has been found to be effective in patients with benign paroxysmal positional vertigo. The initial report 15 on the Epley maneuver indicated an 80 percent success rate after a single treatment and a percent success rate with repeated treatments.
Two subsequent RCTs 18 , 19 reported success rates of 50 to 90 percent. A Cochrane systematic review 20 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 review 20 noted that no long-term assessment was performed in either RCT 18 , 19 on the use of the Epley maneuver.
A study 16 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.
One study 21 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 study 22 reported recurrence rates of 20 percent at 20 months and 37 percent at 60 months. 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. Treatment focuses on symptom relief using vestibular suppressant medications, 6 — 8 followed by vestibular exercises. 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 [Dyazide] often reduce the vertigo, these measures are less effective in treating hearing loss and tinnitus. Ablation of the vestibular hair cells with intratympanic injection of gentamicin also may be effective. The sudden onset of vertigo in a patient with additional neurologic symptoms e. 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.
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. Placement of vertebrobasilar stents may be considered in a patient with symptomatic critical vertebral artery stenosis that is refractory to medical management.
Epidemiologic evidence shows a strong association between vertigo and migraine. One retrospective review 30 found that migraine treatments were effective in about 90 percent of patients with migraine-associated vertigo. Treatments included dietary changes i. Another retrospective chart review 31 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 survey 32 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 [Imitrex].
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Vertigo commonly is associated with anxiety disorders e. 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.
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. A review 34 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. Other medications that are effective in patients with anxiety disorders or depression, such as norepinephrine-serotonin reuptake inhibitors e. 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.
Motion sickness 9 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. Already a member or subscriber? Log in. Address correspondence to Randy Swartz, M. Reprints are not available from the authors. The authors indicate that they do not have any conflicts of interest.
Vertigo and Vertigo-Associated Disorders
Sources of funding: none reported. Guest editor of the series is Tyson Ikeda, M. Acute vestibular syndrome. N Engl J Med.
Dizziness and Vertigo
The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med. Benign paroxysmal positional vertigo. Disorders of equilibrium. Clinical neurology. New York: McGraw-Hill, — Vertigo and hearing loss. American College of Radiology. ACR Appropriateness Criteria. Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs. Baloh RW. Vestibular neuritis. AGA technical review on nausea and vomiting. Fife TD. Episodic vertigo. In: Rakel RE, ed. Philadelphia: Saunders, — Vertigo in older people.
Curr Treat Options Neurol. A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care. Br J Gen Pract. Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg. Vestibular rehabilitation outcomes in patients with a history of migraine. Otol Neurotol. Vestibular exercises improve central vestibulospinal compensation after vestibular neuritis. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo.
Contraindications to the Dix-Hallpike manoeuvre: a multidisciplinary review. Int J Audiol. Randomized trial of the canalith repositioning procedure. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc. Hilton M, Pinder D. Benign paroxysmal positional vertigo BPPV is a condition characterised by episodes of sudden and severe vertigo Content on this website is provided for information purposes only.
Information about a therapy, service, product or treatment does not in any way endorse or support such therapy, service, product or treatment and is not intended to replace advice from your doctor or other registered health professional. The information and materials contained on this website are not intended to constitute a comprehensive guide concerning all aspects of the therapy, product or treatment described on the website.
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Pregnancy and birth services. A-Z A-Z. Conditions and treatments. Healthy living. Services and support. Service profiles. Blog Blog. Blog authors. Podcast Podcast. Dizziness and vertigo Share show more. Listen show more. More show more. Most dizziness is caused by problems of the inner ear and is treatable. Common causes of dizziness related to the inner ear include: benign paroxysmal positional vertigo BPPV , migraine and inflammation of the inner ear balance apparatus vestibular neuritis.
Dizziness may also be caused by other conditions such as low blood pressure, some heart problems, anxiety or low blood sugar.
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The inner ear and balance Inside the inner ear is a series of canals filled with fluid. Very rarely, other causes of dizziness can include stroke or other brain diseases other conditions — some cases of dizziness are due to underlying medical conditions such as low blood pressure , infection, some heart problems such as cardiac arrhythmias and hypoglycaemia low blood sugar.
Medications that are used to treat conditions such as epilepsy, coronary heart disease and high blood pressure can also cause dizziness in some people unknown causes — although a cause may not be found in some people, it does not necessarily mean that these people cannot be helped by the appropriate treatment.
Treatment of dizziness and vertigo Treatment depends on what your doctor thinks is causing your dizziness. Send us your feedback. Rate this website Your comments Questions Your details. Excellent Good Average Fair Poor. Next Submit Now Cancel. Please note that we cannot answer personal medical queries. Enter your comments below optional. Did you find what you were looking for? Yes No. Email Address. Submit Now Cancel. Thank you. Your feedback has been successfully sent.
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Anxiety Disorders - treatment and support video In this video clip, participants discuss the various forms of treatment and support they have received from medical professionals as well as from other sources. Depression explained The most important thing is to recognise the signs and symptoms and seek support