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Therapeutic Interventions in Vertigo Management: Review Article
Therapeutic Interventions in Vertigo Management: Review Article
*Correspondence:
Dr. Kushal Sarda,
E-mail: kushal.sarda@abbott.com
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Vertigo is a condition associated with a spectrum of symptoms and ~30% of general population experience vertigo in
their life time. In spite of being of high clinical importance, the management of vertigo is quite challenging. Though
the literature supports the availability of various therapeutic interventions used in vertigo treatment, their
effectiveness depends on accurate diagnosis, appropriate use of intervention, and physician’s awareness of the overlap
between vestibular, autonomic, and psychological aspects of vestibular pathology. Unfortunately, several drugs act as
tranquilizers and impede the process of vestibular compensation. Betahistine, a histamine analogue, is one of the most
commonly used anti-vertigo drugs worldwide and has been supported by many clinical trials. There have been several
oral communications in international conferences on the efficacy of using betahistine in several clinical vertiginous
syndromes. The current review assesses the use of betahistine 48 mg twice daily for three months as an efficient and
well-tolerated treatment for vertigo. Additionally, it highlights the low incidence of side effects even at high doses of
betahistine and suggests that it may be considered as the first-line of treatment for vestibular dysfunction.
Keywords: Betahistine, Benign paroxysmal positioning vertigo, Peripheral Vertigo, Vestibular dysfunctions,
Vestibular compensation, Meniere's disease
Vertigo presenting as a symptom can have either central The classical symptoms of vertigo include dizziness,
or peripheral cause. Benign paroxysmal positioning imbalance, migraine, nausea, vomiting, sweating, pallor,
vertigo (BPPV) is the most frequent form of peripheral spatial disorientation, and diarrhea. 10 Light-headedness or
Kameshwaran M et al. Int J Otorhinolaryngol Head Neck Surg. 2017 Oct;3(4):777-785
excessive susceptibility to motion-sickness can also be Vestibular rehabilitation with physiotherapy and
seen in some patients.10 Acute vertigo is characterized by management of BPPV, 3. Psychological intervention, 4.
damage to the vestibular elements of the peripheral Pharmacological intervention, and 5. Surgery.11
labyrinth, spontaneous nystagmus away from the affected
ear, and postural instability (ataxia).11
NON-PHARMACOLOGICAL INTERVENTIONS
FOR VERTIGO
Table 1: Forms of vertigo and their prevalence among
17, 718 patients of a German center for vertigo and
Vestibular vertigo should be managed via appropriate
balance disorders.2 strategies so as to attain adequate control over functional
activities such as eye coordination, head, and body
Forms of vertigo Prevalence N (%)
movements. This may further result in appropriate focus,
Benign paroxysmal positional stability, and posture with no adverse symptoms. 12
3036 (17.1)
vertigo Vestibular rehabilitation therapy (VRT) is a non-
Central vestibular syndromes 2178 (12.3) pharmacological exercise-based treatment strategy for
Phobic vestibular vertigo 2661 (15.0) vertigo management. VRT helps in the recovery of
Vestibular migraine 2017 (11.4) vestibular mechanisms such as vestibular adaptation, eye-
Meniere’s disease 1795 (10.1) movement coordination, somatosensory cues, postural
Vestibular neuritis 1462 (8.3) stabilization, and other habituation. The key exercises are
2
Ref: Strupp M, Dieterich M, Brandt T (2013) The Treatment head-eye movements with various body postures and
and Natural Course of Peripheral and Central Vertigo. Dtsch activities, maintaining balance with less or no support in
Arztebl Int 110:505−516. various orientations of the head and trunk while
performing various upper-extremity tasks, repeating the
Vertigo can severely affect the individual’s quality of movements provoking vertigo, and exposing patients
life, who becomes relatively incompetent to undertake gradually to various sensory and motor environments.14
normal work or social activities, has persistent sleep for VRT improves quality of life and postural balance. Yet,
several hours, and an off-balance sensation lasting for in some cases such improvement may also need
several days.11 Vestibular dysfunction in adults may additional pharmacologic treatment.14,15 Other measures
result in serious handicap with considerable psycho- include dietary restriction, lifestyle adaptations and stress
logical morbidity.10 Most of the patients tend to recover reduction techniques.11
within a few weeks, while some may show incomplete
recovery. Diagnosis and identification of co-morbid Psychological disorders may result in incomplete
systemic disorders, such as hypertension, vascular recovery of vertigo. Initial assessment and examination of
disease, type 2 diabetes mellitus and autoimmune the patient’s psychological and avoidance behavior,
syndromes is indispensable as they may affect vestibular together with the study of his mood change can be helpful
compensation if proper treatment is not given. 12,13 in getting a better understanding of his problems. The
Successful therapeutic management depends on accurate presence of avoidance behavior makes patient-
diagnosis, appropriate interventional approaches, and compliance with the VRT program unlikely.11
physician’s awareness of the overlap between vestibular,
autonomic, and psychological aspects of vestibular PHARMACOLOGICAL INTERVENTIONS FOR
pathology.10 TREATMENT OF VERTIGO
Based on the current knowledge on vertigo and its The ideal antivertiginous drug would prevent vomiting
management, the present review attempts to highlight the and dizziness, and promote vestibular compensation. 11
various non-pharmacological and pharmacological The most common group of drugs used in the treatment
therapeutic interventions used in the management of of vertigo are diuretics, antiemetics, histamine analogues,
vertigo. Further, it brings out the awareness about the antihistamines, steroids, antivirals, antimicrobials,
best and effective treatment practices for early control of calcium channel blockers, antidepressants, anti-
this debilitating condition. convulsants, and aminopyridines.1 Antiemetics can be
administered orally (if feasible), intramuscularly, as a
THERAPEUTIC MANAGEMENT OF VERTIGO suppository or via buccal membrane. The pharma-
cological management of vertigo is determined after
The initial step in vertigo management is to reassure and recognizing the underlying reason behind vertigo. The
explain the nature of the symptoms to patients, and give most commonly observed reasons to initiate vertigo
proper hydration if necessary. The systematic treatment are as follows:
rehabilitation plan for each patient should be based on the
diagnosis. The plan includes detailed elucidation to Acute vestibular related clinical presentation.
ensure appropriate understanding and total compliance Causes of vestibular symptoms such as MD and
with the program. The five main pillars of management epilepsy (This involves disease specific treatment).
intervention are as follows: 1. General medical evaluation Any chronic vestibular disorder such as central
with treatment of associated comorbid conditions, 2. vestibular symptomatology (This requires non-
specific but empirical treatment strategy). 12
International Journal of Otorhinolaryngology and Head and Neck Surgery | October-December 2017 | Vol 3 | Issue 4 Page 778
Table 2: Commonly used therapeutic drugs for vertigo.
Effects on
Dose and
Drugs Mechanism of action Side effects vestibular
duration
compensation
Selective calcium channel blocker,
acts predominantly on the peripheral
vestibular labyrinth by affecting
local calcium ion flux
Sedation
Lowers whole blood viscosity, and Delays
75 mg/day Pedal edema
Cinnarizine 12,20-23
Is effective for vertiginous vestibular
for 3 days Extrapyramidal
syndrome caused by over-reactivity compensation
disorders
or unbalanced activity of
labyrinthine apparatus in the inner
ear
Suppresses the eye
movement response or
nystagmus
Cinnarizine regulates vestibular
calcium influx of the labyrinth
and improves cerebral circulation
Cinnarizin Dimenhydrinate regulates
e 20 mg+ vestibular nuclei and adjacent Effect on
Cinnarizine + Delays
dimenhydr vegetative centers in the brain- occupation and
Dimenhydrinate22, vestibular
24- 27 inate 40 stem cognition extra
compensation
mg/day for The actions of cinnarizine pyramidal side effects
3 days are reinforced by High somnolence
dimenhydrinate
The fixed combination effectively
reduces the vertigo symptoms and
decreased the concomitant
vegetative
symptoms
Increases cochlear and
vestibular blood flow
Mild side effects
Increases histamine turnover in the
48 including Facilitates
central nervous and vestibular
Betahistine1, 22, 28 mg/day, 3- gastrointestinal vestibular
system
6 months complaints, fatigue compensation
Increase in the level of histamine
and altered taste
in damaged vestibular nuclei
reduces inhibition by intact
vestibular nuclei
by H3 hetero-antagonistic action
Extrapyramidal
symptoms
Drowsiness
Decreases abnormal excitement and dizziness
Prochlorperazine
in the brain Dry mouth Delays
10-15
29, 30 No effect upon any measure of Headache vestibular
mg/day
nystagmic or perceptual vestibular compensation
Fever
function
Muscle stiffness
Irregular heartbeat
Sweating
Causes inhibition throughout Drowsiness
Delays
15, 31 5 mg/6 to the central nervous system, Dizziness
Diazepam vestibular
8 hours including activity in the vestibular Respiratory
compensation
nerve and vestibular nuclei depression
Combination of drugs belonging to the same class, vestibular suppressants and/or tranquilizers is
however, is not recommended. 16 Long term use of counterproductive for vestibular compensation. These drugs
should be recommended only for truly acute vertigo and use of anticholinergic agents which are used in the
stopped as soon as the symptoms of vertigo recede. 17 The management of vertigo such as dry mouth, dilated pupils,
prominent side effects associated with the and sedation, especially in elderly people with vertigo
also restrict their use.18