| Cause | Treatment | Comments |
|---|---|---|
| Vertigo | ||
| Benign paroxysmal positional vertigo | Meclizine (Antivert), 25 to 50 mg orally every four to six hours | Commonly used to reduce symptoms of acute episodes of vertigo, although there are no RCTs to support its use; use of vestibular suppressants can lead to brainstem compensation and prolong vertiginous symptoms |
| Epley maneuver (canalith repositioning; see Figure 3) | Main benign paroxysmal positional vertigo treatment; safe and effective compared with placebo; video demonstration is available at http://www.youtube.com/watch?v=ZqokxZRbJfw&NR=1 | |
| Vestibular rehabilitation | Series of head and neck exercises that can be performed daily at home; video demonstration available at http://www.youtube.com/watch?v=hhinu_oU_hM | |
| Evidence for balance therapy (e.g., tai chi, Wii Fit) is accumulating | ||
| Meniere disease | Salt restriction (less than 1 to 2 g of sodium per day) and/or diuretics (most commonly, hydrochlorothiazide/triamterene [Dyazide]) | No large-scale RCTs to support these therapies |
| Intratympanic dexamethasone or gentamicin | Referral to an otolaryngologist required; in one small study, dexamethasone resolved symptoms in 82 percent of patients; in a larger study, gentamicin resolved symptoms in 80.7 percent of patients46,47 | |
| Endolymphatic sac surgery | Referral to an otolaryngologist required | |
| Vestibular neuritis | Methylprednisolone (Depo-Medrol), initially 100 mg orally daily then tapered to 10 mg orally daily over three weeks | In an RCT, methylprednisolone was more effective in improving peripheral vestibular function than valacyclovir (Valtrex) in patients with vestibular neuritis49 |
| Migrainous vertigo | Migraine prophylaxis with serotonin 5-HT1 receptor agonists (triptans) | Treatment based on expert opinion, not RCTs |
| Presyncope | ||
| Orthostatic hypotension | Review medication regimen | This is the first step, especially in older patients; rehydration (even increased water intake) can improve symptoms, especially in those with autonomic failure |
| Midodrine (Proamatine) titrated up to 10 mg orally three times daily | Alpha-1 agonist metabolite; to avoid supine hypertension, the third dose should be given by 6 p.m.; should be used only in severely impaired patients; in placebo-controlled trials, midodrine was associated with increased standing blood pressures and fewer orthostatic symptoms compared with placebo36 | |
| Fludrocortisone, initially 0.1 mg orally daily, titrated up weekly until peripheral edema develops or to a maximal dosage | Mineralocorticoids, such as fludrocortisone, are used to increase sodium and water retention; monitor blood pressure, potassium level, and for symptoms of heart failure | |
| Fludrocortisone and midodrine can be used in combination if either agent alone fails to control symptoms | ||
| Pseudoephedrine, 30 to 60 mg orally daily Paroxetine (Paxil), 20 mg orally daily | These drugs are options when midodrine and fludrocortisone are ineffective | |
| Desmopressin (DDAVP), 5 to 40 mcg intranasally daily | Nondrug therapy includes replacement of fluids, rising slowly from lying or sitting positions, sleeping with the head of the bed elevated, increasing salt intake, and regular exercise | |
| Disequilibrium | Treatment of underlying cause (e.g., peripheral neuropathy, Parkinson disease) | Because disequilibrium is generally a symptom of an underlying condition, treatment of the condition improves symptoms of disequilibrium |
| Lightheadedness | ||
| Hyperventilation syndrome | Breathing control exercises, rebreathing into a small paper bag | Reverses hypocapnia-related symptoms |
| Beta blockers | Treats associated symptoms, such as palpitations and sweating; not for use in patients with asthma | |
| Antianxiety agents (e.g., selective serotonin reuptake inhibitors) or short-term use of benzodiazepines | For use in patients with underlying anxiety | |