Treatment Options for Vertigo

By Dr. Prateek Porwal, ENT Surgeon & Vertigo Specialist | PRIME ENT CENTER, Hardoi UP
Last Updated: February 2026 | VAI Budapest 2025 Award Recipient

The question I hear most often is “Doctor, what is the treatment for my vertigo?” The honest answer is: it depends completely on your diagnosis. BPPV needs a repositioning maneuver, not medication. Vestibular neuritis needs exercises, not maneuvers. Meniere’s disease needs dietary modification and possibly surgery. Vestibular migraine needs migraine prevention. There’s no one-size-fits-all treatment. Let me explain the treatment options for vertigo condition by condition.

BPPV Treatment: Repositioning Maneuvers

The Epley Maneuver (Most Common)

Specifically targets posterior canal BPPV (the most common type). Uses gravity to reposition dislodged crystals back into the utricle.

How it works: Doctor moves patient’s head through specific positions: neck extended, head back and to side, sitting forward, head turned. Each position keeps loose crystals moving into different areas. Goal: move crystals back into utricle where they belong.

Success rate: 85-95% resolution after 1-2 sessions. Remarkably effective once diagnosis confirmed.

Important: Maneuver must be done by someone trained—wrong technique doesn’t work. Also, patient must understand post-treatment precautions: sleep elevated for one week, avoid the triggering head movement for 1-2 weeks, no bending forward.

The Semont Maneuver (Alternative)

Alternative to Epley. Instead of backward head extension, uses rapid side-to-side positioning. Some patients prefer it (especially elderly with neck problems). Equally effective if done correctly.

The Barbecue Roll (Dix-Hallpike Variant)

Particularly effective for horizontal canal BPPV. Patient rolls slowly on the bed like meat on a barbecue spit. Repositions crystals in horizontal canal. Named by Bangalore researchers, very effective for certain BPPV presentations.

Home Maneuvers

Once maneuver works and BPPV resolves, I teach patients home maneuvers. If BPPV recurs (and it does in 30% of patients over 5 years), patient can treat it at home.

Important: No medication needed before or after maneuver in most cases. No prolonged PT. Just the maneuver, post-treatment precautions, done.

Vestibular Neuritis and Labyrinthitis Treatment

Acute Phase (First 3-7 Days)

Anti-nausea medication: Ondansetron is gentler than older antihistamines. Controls nausea so patient can tolerate movement.

Vestibular suppressants (briefly): Dimenhydrinate or meclizine for first few days if severe dizziness. Should NOT continue beyond acute phase—they inhibit neuroplasticity and slow recovery.

Bed rest during acute phase: While severe, rest is appropriate. Once nausea improves (usually 3-7 days), movement becomes essential.

Recovery Phase (Weeks 1-12)

Vestibular rehabilitation therapy (VRT): This is the primary treatment. Specific exercises that train the brain to compensate for vestibular loss. Must be started early and done consistently.

Progression:

• Week 1-2: Gentle gaze stabilization exercises, simple balance training
• Week 2-4: More challenging exercises, balance with more difficulty
• Week 4-12: Advanced exercises, real-world balance challenges

No medication during recovery phase: Vestibular suppressants inhibit the brain’s adaptation. Patient should not take them during recovery. Some initial dizziness during exercises is normal and necessary for brain adaptation.

Corticosteroids: Controversial

Some evidence (debated) that early corticosteroids (high-dose prednisone started within 2-3 weeks of symptom onset) may improve vestibular neuritis outcomes. Benefits are modest if real. Not standard of care yet. I consider it in severe cases starting early.

Meniere’s Disease Treatment: Stepwise Approach

First Line: Diet and Diuretics

Low-sodium diet: Salt restriction to 1500-2000mg daily reduces fluid retention in inner ear. Helps 50-60% of patients over 3-6 months.

Diuretics (especially thiazide type): Furosemide or hydrochlorothiazide reduces inner ear fluid volume. Combined with low-sodium diet, helps most patients. Few side effects if monitored.

Betahistine (vasodilator): Medication that may improve inner ear blood flow and fluid dynamics. Helps 40-50% of patients. Safe, minimal side effects. Used much in Europe, less in US, increasing use worldwide.

Success rate of first-line: 70-80% of Meniere’s patients control symptoms with diet + diuretics ± betahistine.

Second Line: Intratympanic Therapy

Intratympanic corticosteroids: Steroid injected through eardrum into middle ear, crosses round window into inner ear. Reduces inflammation. Can be done in office. May help both hearing and vertigo. Typically 4 injections over 2-3 weeks. Reasonably well-tolerated.

Intratympanic gentamicin: Antibiotic gentamicin injected into inner ear. Damages vestibular system more than hearing system, reducing vertigo episodes. Risk: hearing loss. Reserved for uncontrolled vertigo despite medical management. Some prefer corticosteroids first.

Success rate: 60-70% obtain significant vertigo control

Third Line: Surgery

Endolymphatic sac decompression: Surgical decompression of endolymphatic sac to improve fluid drainage. Controversial—some studies show benefit, others don’t. Used less often now.

Labyrinthectomy: Surgical destruction of vestibular function in affected ear. Reserved for severe uncontrolled vertigo when all else fails. Causes permanent balance loss on that side but may help vertigo. Only considered when vertigo is severely disabling and patient willing to accept permanent balance loss.

Vestibular nerve section: Surgical cutting of vestibular nerve while preserving hearing nerve. Theoretically ideal—eliminates vertigo while preserving hearing. But major surgery with real risks. Reserved for very severe cases.

Vestibular Migraine Treatment

Trigger Identification and Avoidance

Essential first step. Common triggers: stress, sleep deprivation, hunger, skipped meals, bright lights, loud sounds, certain foods (chocolate, processed foods with MSG, aged cheese, red wine, cured meats).

Keep migraine diary: Track vertigo episodes, potential triggers. Patterns emerge—avoiding triggers often dramatically reduces episodes.

Migraine Prevention Medications

Propranolol (beta-blocker): First-line. Dose 40-160mg daily. Effective for 50-60% of patients. Side effects: fatigue, sexual dysfunction, contraindicated with asthma.

Topiramate (anticonvulsant): Effective for 50-60%. Side effects: cognitive dulling, weight loss, tingling in extremities. Better tolerated than some others.

Amitriptyline (tricyclic antidepressant): Effective, especially if patient also has anxiety or sleep problems. Side effects: sedation, weight gain, constipation.

CGRP inhibitors (newer): Erenumab, fremanezumab, galcanezumab. Show promise specifically for vestibular symptoms. Monthly injections. Very expensive but increasingly used.

Choice based on: Patient comorbidities (depression? asthma? need for weight loss?), side effect tolerance, previous migraine medication trials.

Acute Episode Treatment

Triptans: Sumatriptan, rizatriptan others. Effective for acute migraine with or without headache. Usually well-tolerated.

Supportive care: Dark quiet room, rest, ice/heat as tolerated.

PPPD (Persistent Postural Perceptual Dizziness) Treatment

Not a structural problem: PPPD is brain dysfunction (central sensitization). Medication alone doesn’t fix it. Requires cognitive-behavioral therapy + graded vestibular rehabilitation.

Cognitive-behavioral therapy: Addresses catastrophic thinking, anxiety about vertigo, avoidance behaviors. Helps retrain brain’s response to balance threats.

Graded vestibular rehabilitation: Progressive exposure to dizziness-triggering situations in controlled safe way. Habituation occurs.

SSRIs (antidepressants): Sometimes helpful for associated anxiety. Not curative but supportive.

Important: Patients often tried many medications without benefit. That’s because medication isn’t the answer for PPPD. Reframing problem as central sensitization needing brain retraining (not inner ear problem needing medication) is key to improvement.

Anxiety-Related Dizziness

Treat the anxiety disorder: SSRIs, cognitive-behavioral therapy, mindfulness meditation.

Breathing exercises: Panic-related dizziness responds well to proper breathing (slow diaphragmatic breathing, avoiding hyperventilation).

Reassurance: Once patient understands dizziness is from anxiety, not heart attack or stroke, anxiety often improves (reduces catastrophic thinking).

What NOT to Do: Common Mistakes

Don’t give long-term vestibular suppressants for BPPV: Once maneuver works, medication becomes unnecessary and may mask recurrence.

Don’t do prolonged bed rest for vestibular neuritis: Movement is healing; bed rest delays recovery.

Don’t use long-term betahistine for BPPV: Betahistine helps Meniere’s, not BPPV. Using it in wrong diagnosis wastes money and delays proper treatment.

Don’t use benzodiazepines routinely: Diazepam, lorazepam increase fall risk, cause dependency. Avoid except acutely.

Don’t give stemetil (prochlorperazine) without diagnosis: Common mistake in India—prescribe anti-nausea med for any dizziness without identifying cause. May mask symptoms or delay diagnosis.

Don’t order MRI for straightforward BPPV: Diagnosis is clinical. Imaging not needed if Dix-Hallpike positive.

India-Specific Treatment Issues

Overuse of betahistine: Prescribed for all vertigo in India. Actually helps only Meniere’s disease. Waste of money if diagnosis is BPPV or vestibular neuritis.

Lack of trained practitioners for maneuvers: Many areas don’t have doctors trained in Epley maneuver. Patients suffer needlessly. Telemedicine consultation can guide local doctor through maneuver.

Vitamin D deficiency not addressed: Simple supplementation prevents BPPV recurrence. Almost never prescribed, missing easy intervention.

Limited VRT availability: No vestibular physiotherapists in many areas. Home exercises with proper instruction often work, but access to trained PT limited.

Cost constraints: Expensive medications, procedures, imaging sometimes recommended but unaffordable. Most vestigo is treatable with inexpensive, simple measures.

Frequently Asked Questions About Vertigo Treatment

What is the most effective treatment for BPPV?

The Epley maneuver or other repositioning maneuvers. Success rate 85-95%. Better than any medication. Quick, effective, permanent (until BPPV recurs, which happens in minority). No medication needed.

Will I need surgery for vertigo?

Rarely. Surgery is last resort for severe, uncontrolled Meniere’s disease when all medical options exhausted. Most vertigo is successfully managed medically or with rehabilitation. Don’t assume surgery is needed.

Should I take medication long-term for vertigo?

Depends on diagnosis. BPPV: no long-term medication after maneuver. Vestibular neuritis: no long-term medication once recovered. Meniere’s: possibly long-term (diet, diuretics, betahistine). Vestibular migraine: yes, migraine prevention medication. Determine diagnosis first; medication follows.

Are there new treatments I haven’t heard of?

VR-based rehabilitation, CGRP inhibitors for migraine, intratympanic therapies—these are newer options. But traditional treatments (maneuvers, VRT, migraine prevention) remain most effective. Don’t chase novelty without evidence.

Can I do vestibular rehabilitation at home?

Yes. Basic exercises can be done at home with proper instruction. Professional PT helpful for complex cases. But many patients improve with self-directed home exercises if given clear instructions and follow-up.

How do I know if my treatment is working?

Keep a symptom diary. Rate dizziness 0-10 daily. Track activities. After weeks-months of treatment, patterns should show improvement (fewer episodes, less severe, returning to normal activities). If no improvement after 4-6 weeks, reassess diagnosis.

When to Seek Specialist Evaluation: Red Flags and Special Circumstances

You should see a vestibular specialist if:

• Vertigo is severe or disabling
• Diagnosis is unclear despite initial evaluation
• First-line treatment isn’t working (BPPV maneuver fails, VRT not improving symptoms)
• You have atypical symptoms (vertical nystagmus, progressive neurological signs)
• Associated with hearing loss, facial weakness, or other neurological signs
• Recurrent episodes suggesting Meniere’s or migraine requiring specialist management
• Considering surgical options

Long-Term Management and Prevention of Recurrence

BPPV recurrence prevention: Vitamin D supplementation (2000-4000 IU daily) reduces recurrence. If deficient, correct it. Avoid head trauma, fall risks. Some patients have recurrent BPPV—teach them home Epley maneuver for self-treatment if it returns.

Vestibular neuritis prevention: Once recovered, no specific prevention. Risk of second episode low (different side usually affected if occurs). Continue VRT exercises periodically to maintain balance.

Meniere’s prevention: Maintenance of low-sodium diet, diuretics if prescribed, adequate hydration. Some patients find stress reduction helps. Regular follow-up important to monitor hearing.

Vestibular migraine prevention: Trigger identification and avoidance crucial. Migraine prophylactic medication continued long-term. Sleep, stress management, avoiding hunger/dehydration essential.

India-Specific Treatment Challenges and Solutions

Limited access to specialists in rural areas: Telemedicine consultation bridges gap. Initial specialist evaluation via video, then local doctor implements treatment plan.

Unavailability of Epley-trained practitioners: Solution: seek training for ENT specialists in your area. Certification courses available. Telemedicine can guide procedure.

Cost of investigations: Many investigations (VNG, imaging) expensive. Diagnosis often possible clinically. Don’t order tests unless diagnosis uncertain. Clinical assessment often sufficient.

Medication costs: CGRP inhibitors expensive (beyond most patients’ means). Traditional migraine prophylaxis (propranolol, topiramate) much cheaper and often effective.

Physical therapy access: Home exercises with proper instruction often work as well as formal PT. Teach family to supervise. Video guidance helpful.

Patient expectations: Some expect overnight cure. Education that recovery takes weeks-months important. Consistent effort with exercises matters more than initial treatment modality.