Vertigo Management

1. See Also
   1. Vertigo
   2. Vertigo Causes
   3. Peripheral Causes of Vertigo
   4. Central Causes of Vertigo
   5. Meniere's Disease
   6. Motion Sickness
   7. Vestibular Neuronitis
   8. Benign Paroxysmal Positional Vertigo
   9. Perilymphatic Fistula (Hennebert's Sign)
   10. Acute Labyrinthitis
   11. Bacterial Labyrinthitis (Acute Suppurative Labyrinthitis)
   12. HiNTs Exam (Three-Step Bedside Oculomotor Examination)
   13. Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
   14. Nystagmus
   15. Skew Deviation (Vertical Ocular Misalignment, Vertical Heterotropia, Vertical Strabismus)
   16. Dix-Hallpike Maneuver
   17. Dizziness
   18. Dysequilibrium
   19. Syncope
   20. Light Headedness
2. General
   1. Evaluate and treat specific Vertigo Causes
   2. Medications are indicated for symptomatic acute Vertigo
   3. Avoid longstanding use of symptomatic medications
      1. Stop medications to allow brain to equilibrate
   4. Early ambulation improves rate of recovery
   5. Rehabilitation Exercises
      1. Epley Maneuver
         1. Indicated for Benign Paroxysmal Positional Vertigo (BPPV)
      2. Prescribed program of head movements and activity
         1. Improves symptom adaptation and balance
         2. Yardley (2004) Ann Intern Med 141:598-605 [PubMed]
3. Management: Symptomatic Therapy - Outpatient
   1. Precautions
      1. Limit to 3 days only (to allow central compensation to proceed)
   2. Over the counter medications (Category B in pregnancy)
      1. Meclizine (Antivert)
         1. Age >12 years: 25 mg orally every 6 hours as needed
         2. Precaution: Sedating
      2. Dimenhydrinate (Dramamine)
         1. Preferred as better Anti-emetic effect and less sedation than Meclizine
         2. Adults: 50-100 mg orally every 4-6 hours (max: 400 mg/day)
         3. Age 2-5: 12.5-25 mg orally every 6-8 hours (max: 75 mg/day)
         4. Age 6-12: 25-50 mg orally every 6-8 hours (max: 150 mg/day)
   3. Antiemetics
      1. Ondansetron ODT (Zofran ODT) 4 mg IV/IM/PO every 6 hours as needed
      2. Metoclopramide (Reglan) 10 mg orally every 6 hours as needed
   4. Benzodiazepines for severe symptoms (adult dosing)
      1. Avoid in most cases of outpatient Vertigo Management
      2. Diazepam (Valium) 5-10 mg orally every 6 hours
      3. Lorazepam (Ativan) 0.5-2 mg orally every 6 hours
4. Management: Symptomatic Therapy - Emergency Department
   1. First Line agents with dual Anti-emetic and anti-Vertigo activity
      1. Promethazine (Phenergan)
         1. Dose: 6.25 to 12.5 mg slow IV push (or 12.25 to 25 mg IM/PO/PR) as needed every 6 hours
         2. Consider Ondansetron instead in the elderly due to Anticholinergic effects
      2. Dimenhydrinate (Dramamine)
         1. Dose: 50 mg IV every 4 to 6 hours prn
         2. Limited availability
   2. Other Anti-emetics
      1. Prochlorperazine (Compazine) 5-10 mg IV/IM every 3-4 hours as needed
      2. Ondansetron (Zofran) 4 mg IV/IM/PO every 6 hours as needed
   3. Other anti-Vertigo
      1. Lorazepam (Ativan) 0.5 to 2 mg IV/IM/PO every 6 hours as needed
      2. Diazepam (Valium) 2 mg IV or 5 mg IM/PO every 6 hours as needed
5. References
   1. Ondrejka (2014) Crit Dec Emerg Med 28(10): 11-7
   2. Marill (2000) Ann Emerg Med 36:310-9 [PubMed]
   3. Swartz (2005) Am Fam Physician 71:1115-30 [PubMed]