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What’s the Best Treatment for Peripheral Vertigo?

December 19, 2022

Written by Aaron Lacy

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Vestibular suppressant medications in peripheral vertigo were not associated with symptom resolution, decrease in repeat ED visits, patient satisfaction, or increased quality of life. The authors suggest that positional maneuvers, such as the Epley maneuver, should be the primary treatment for BPPV.

Why does this matter?
Vertigo is a challenging, but common, chief complaint in the ED. JournalFeed has covered the pitfalls of delineating peripheral versus central causes of vertigo, which can be challenging. When a patient presents with certain BPPV, knowing the most effective treatment is essential.

Are vestibular suppressants just smoke and mirrors?
Five RCTs, totaling 296 patients, were included in this quantitative analysis looking at symptom resolution of vertigo symptoms with medical treatment of BPPV (diagnosis confirmed by Dix-Hallpike maneuver). These medications included benzodiazepines, antiemetics, and antihistamines. Three of the five RCTs had canalith repositioning maneuvers as the control arm.  Vestibular suppressants had no effect on symptom resolution after 14 to 31 days; difference -0.03 (95%CI -0.53 to 0.47). There was also uncertain to no effect on symptom resolution at 24 hours, patient satisfaction, quality of life, ED return visits, and adverse events. Conversely, they found canalith repositioning maneuvers may improve symptom resolution when compared to medication (RR 0.63, 95%CI 0.52 to 0.78).

Low enrollment and some study heterogeneity led to low certainty of evidence, but my takeaway is still clear – vertigo just keeps getting more challenging for the ED physician. Physical exam by the ED physician to delineate peripheral versus central causes is contentious and even advanced neuroimaging is not certain. Now it seems that commonly prescribed medications might not even be helpful. After reading this study I will be reviewing the Epley maneuver so I can better help my patients on shift.

Editor’s note: The Carol Foster (half somersault) maneuver is also very effective. ~Clay Smith

Extra spoonful: A Cochrane review of the Epley maneuver found a NNT of 3.

Vestibular suppressants for benign paroxysmal positional vertigo: A systematic review and meta-analysis of randomized controlled trials. Acad Emerg Med. 2022 Oct 21. doi: 10.1111/acem.14608. Online ahead of print.

What are your thoughts?