Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

viral: non-HIV

1st line – vestibular suppressant/antiemetic

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ACUTE
|
viral: non-HIV
1st line – 

vestibular suppressant/antiemetic

Symptoms of acute vertigo episodes can be treated with vestibular suppressants and antiemetics. Much of the effect is from the sedating action of these drugs, therefore warn patients about driving and operating equipment while being treated. Only one agent should be used at a time.

Commonly used treatments include antihistamines with anticholinergic properties (e.g., promethazine, dimenhydrinate) and antiemetics (e.g., prochlorperazine, metoclopramide, ondansetron).[34] Metoclopramide should be used for up to 5 days only to minimize the risk of neurologic and other adverse effects. It is not recommended for this indication in children.[35] 

The acute vertigo symptoms typically resolve over 72 hours.

Consider fluid and electrolyte imbalances, particularly if the patient has had prolonged nausea and vomiting. Obtaining a basic metabolic panel before and after treatment, and initiating intravenous hydration, may be necessary in these patients.

Primary options

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg every 4-6 hours when required, maximum 400 mg/day

OR

prochlorperazine maleate: children 2-12 years of age and 9-13 kg: 2.5 mg orally every 12-24 hours when required, maximum 7.5 mg/day; children 2-12 years of age and 14-17 kg: 2.5 mg orally every 8-12 hours when required, maximum 10 mg/day; children 2-12 years of age and 18-39 kg: 2.5 mg orally every 8 hours when required, maximum 15 mg/day; adults: 5-10 mg orally every 6-8 hours when required, maximum 40 mg/day

OR

metoclopramide: adults: 5-10 mg orally/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

OR

ondansetron: children and adults: consult specialist for guidance on dose

Consider – corticosteroid

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ACUTE
|
viral: non-HIV
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

For patients with sudden sensorineural hearing loss, corticosteroids are considered the standard of care.[32]

Treatment course: 10 to 14 days with a 5-day taper.

Primary options

prednisone: children: 1 mg/kg/day orally; adults: 60 mg/day orally

bacterial: secondary to otitis media

1st line – treatment of underlying condition

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ACUTE
|
bacterial: secondary to otitis media
1st line – 

treatment of underlying condition

If the history and exam are consistent with otitis media, such as otalgia (ear pain) and an abnormal ear exam suggesting fluid, redness, or pus behind the ear drum, without systemic signs of infection (i.e., fever, chills), then topical antibiotics should be prescribed.

Ear drops deliver antibiotic concentrations several orders of magnitude above minimum inhibitory concentrations that are obtained with culture and sensitivity testing.[36] 

For those with tympanic membrane perforation and purulent otorrhea, the ear should be cleaned before topical therapy.

Oral antibiotics are not typically indicated unless the patient has systemic signs of infection (i.e., fever, chills).

Following a series of acute otitis media infections, the patient may require myringotomy (surgical incision of the ear drum) with pressure equalization tube placement.

Please refer to our topic on Acute otitis media for more information.

Plus – vestibular suppressant/antiemetic

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ACUTE
|
bacterial: secondary to otitis media
Plus – 

vestibular suppressant/antiemetic

Treatment recommended for ALL patients in selected patient group

Symptoms of acute vertigo episodes can be treated with vestibular suppressants and antiemetics. Much of the effect is from the sedating action of these drugs, therefore warn patients about driving and operating equipment while being treated. Only one agent should be used at a time.

Commonly used treatments include antihistamines with anticholinergic properties (e.g., promethazine, dimenhydrinate) and antiemetics (e.g., prochlorperazine, metoclopramide, ondansetron).[34] Metoclopramide should be used for up to 5 days only to minimize the risk of neurologic and other adverse effects. It is not recommended for this indication in children.[35] 

The acute vertigo symptoms typically resolve over 72 hours.

Consider fluid and electrolyte imbalances, particularly if the patient has had prolonged nausea and vomiting. Obtaining a basic metabolic panel before and after treatment, and initiating intravenous hydration, may be necessary in these patients.

Primary options

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg every 4-6 hours when required, maximum 400 mg/day

OR

prochlorperazine maleate: children 2-12 years of age and 9-13 kg: 2.5 mg orally every 12-24 hours when required, maximum 7.5 mg/day; children 2-12 years of age and 14-17 kg: 2.5 mg orally every 8-12 hours when required, maximum 10 mg/day; children 2-12 years of age and 18-39 kg: 2.5 mg orally every 8 hours when required, maximum 15 mg/day; adults: 5-10 mg orally every 6-8 hours when required, maximum 40 mg/day

OR

metoclopramide: adults: 5-10 mg orally/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

OR

ondansetron: children and adults: consult specialist for guidance on dose

bacterial: secondary to meningitis

1st line – treatment of underlying condition

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ACUTE
|
bacterial: secondary to meningitis
1st line – 

treatment of underlying condition

If intracranial infection (e.g., meningitis) is suspected, prompt treatment with intravenous antibiotics is indicated.

Topical antibiotics are recommended if otorrhea is also present.

Please refer to our topic on Bacterial meningitis for more information.

Plus – vestibular suppressant/antiemetic

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ACUTE
|
bacterial: secondary to meningitis
Plus – 

vestibular suppressant/antiemetic

Treatment recommended for ALL patients in selected patient group

Symptoms of acute vertigo episodes can be treated with vestibular suppressants and antiemetics. Much of the effect is from the sedating action of these drugs, therefore warn patients about driving and operating equipment while being treated. Only one agent should be used at a time.

Commonly used treatments include antihistamines with anticholinergic properties (e.g., promethazine, dimenhydrinate) and antiemetics (e.g., prochlorperazine, metoclopramide, ondansetron).[34] Metoclopramide should be used for up to 5 days only to minimize the risk of neurologic and other adverse effects. It is not recommended for this indication in children.[35] 

The acute vertigo symptoms typically resolve over 72 hours.

Consider fluid and electrolyte imbalances, particularly if the patient has had prolonged nausea and vomiting. Obtaining a basic metabolic panel before and after treatment, and initiating intravenous hydration, may be necessary in these patients.

Primary options

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg every 4-6 hours when required, maximum 400 mg/day

OR

prochlorperazine maleate: children 2-12 years of age and 9-13 kg: 2.5 mg orally every 12-24 hours when required, maximum 7.5 mg/day; children 2-12 years of age and 14-17 kg: 2.5 mg orally every 8-12 hours when required, maximum 10 mg/day; children 2-12 years of age and 18-39 kg: 2.5 mg orally every 8 hours when required, maximum 15 mg/day; adults: 5-10 mg orally every 6-8 hours when required, maximum 40 mg/day

OR

metoclopramide: adults: 5-10 mg orally/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

OR

ondansetron: children and adults: consult specialist for guidance on dose

Consider – corticosteroid

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ACUTE
|
bacterial: secondary to meningitis
Consider – 

corticosteroid

Treatment recommended for SOME patients in selected patient group

The use of oral corticosteroids can reduce the severity and incidence of hearing loss in patients with pneumococcal meningitis.[37] Practice guidelines for the management of bacterial meningitis indicate that the use of adjunctive dexamethasone in infants and children with bacterial meningitis demonstrated clinical benefit for hearing outcomes. For example, in patients with meningitis caused by Haemophilus influenzae type b, dexamethasone reduced hearing impairment overall, whereas in patients with pneumococcal meningitis, dexamethasone only suggested protection for severe hearing loss if given early.[38]

Corticosteroids decreased the rate of hearing loss in children with meningitis due to H influenzae (4% vs. 12%), but not in children with meningitis due to other bacteria. However, Cochrane recommends the use of corticosteroids (e.g., dexamethasone) before, or with, the first dose of antibiotics in adults and children with acute bacterial meningitis in high‐income countries.[37]

Primary options

dexamethasone sodium phosphate: children ≥1 month of age: 0.15 mg/kg intravenously every 6 hours for 2-4 days; adults: 10 mg intravenously every 6 hours for 2-4 days

bacterial: syphilitic

1st line – treatment of underlying condition

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ACUTE
|
bacterial: syphilitic
1st line – 

treatment of underlying condition

Patients with positive syphilis serology should be treated with an appropriate course of antibiotics and may warrant a thorough evaluation by an infectious disease specialist.[6]

Please refer to our topic on Syphilis infection for more information.

Plus – vestibular suppressant/antiemetic

Back
ACUTE
|
bacterial: syphilitic
Plus – 

vestibular suppressant/antiemetic

Treatment recommended for ALL patients in selected patient group

Symptoms of acute vertigo episodes can be treated with vestibular suppressants and antiemetics. Much of the effect is from the sedating action of these drugs, therefore warn patients about driving and operating equipment while being treated. Only one agent should be used at a time.

Commonly used treatments include antihistamines with anticholinergic properties (e.g., promethazine, dimenhydrinate) and antiemetics (e.g., prochlorperazine, metoclopramide, ondansetron).[34] Metoclopramide should be used for up to 5 days only to minimize the risk of neurologic and other adverse effects. It is not recommended for this indication in children.[35] 

The acute vertigo symptoms typically resolve over 72 hours.

Consider fluid and electrolyte imbalances, particularly if the patient has had prolonged nausea and vomiting. Obtaining a basic metabolic panel before and after treatment, and initiating intravenous hydration, may be necessary in these patients.

Primary options

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg every 4-6 hours when required, maximum 400 mg/day

OR

prochlorperazine maleate: children 2-12 years of age and 9-13 kg: 2.5 mg orally every 12-24 hours when required, maximum 7.5 mg/day; children 2-12 years of age and 14-17 kg: 2.5 mg orally every 8-12 hours when required, maximum 10 mg/day; children 2-12 years of age and 18-39 kg: 2.5 mg orally every 8 hours when required, maximum 15 mg/day; adults: 5-10 mg orally every 6-8 hours when required, maximum 40 mg/day

OR

metoclopramide: adults: 5-10 mg orally/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

OR

ondansetron: children and adults: consult specialist for guidance on dose

HIV-associated

1st line – treatment of underlying condition

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ACUTE
|
HIV-associated
1st line – 

treatment of underlying condition

Patients with HIV-associated labyrinthitis should be referred to a physician with experience in managing HIV patients.

Please refer to our topic on HIV infection for more information.

Plus – vestibular suppressant/antiemetic

Back
ACUTE
|
HIV-associated
Plus – 

vestibular suppressant/antiemetic

Treatment recommended for ALL patients in selected patient group

Symptoms of acute vertigo episodes can be treated with vestibular suppressants and antiemetics. Much of the effect is from the sedating action of these drugs, therefore warn patients about driving and operating equipment while being treated. Only one agent should be used at a time.

Commonly used treatments include antihistamines with anticholinergic properties (e.g., promethazine, dimenhydrinate) and antiemetics (e.g., prochlorperazine, metoclopramide, ondansetron).[34] Metoclopramide should be used for up to 5 days only to minimize the risk of neurologic and other adverse effects. It is not recommended for this indication in children.[35] 

The acute vertigo symptoms typically resolve over 72 hours.

Consider fluid and electrolyte imbalances, particularly if the patient has had prolonged nausea and vomiting. Obtaining a basic metabolic panel before and after treatment, and initiating intravenous hydration, may be necessary in these patients.

Primary options

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg every 4-6 hours when required, maximum 400 mg/day

OR

prochlorperazine maleate: children 2-12 years of age and 9-13 kg: 2.5 mg orally every 12-24 hours when required, maximum 7.5 mg/day; children 2-12 years of age and 14-17 kg: 2.5 mg orally every 8-12 hours when required, maximum 10 mg/day; children 2-12 years of age and 18-39 kg: 2.5 mg orally every 8 hours when required, maximum 15 mg/day; adults: 5-10 mg orally every 6-8 hours when required, maximum 40 mg/day

OR

metoclopramide: adults: 5-10 mg orally/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

OR

ondansetron: children and adults: consult specialist for guidance on dose

autoimmune

1st line – treatment of underlying condition

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ACUTE
|
autoimmune
1st line – 

treatment of underlying condition

Patients with autoimmune-associated labyrinthitis (e.g., Cogan syndrome or Behcet disease) may respond to oral corticosteroids.

In cases of corticosteroid nonresponsiveness, the use of alternative immunomodulators may stabilize or improve hearing and balance while avoiding the adverse effects of taking long-term corticosteroids.

Consult specialist for guidance on dose.

Please refer to our topic on Behcet syndrome for more information.

Plus – vestibular suppressant/antiemetic

Back
ACUTE
|
autoimmune
Plus – 

vestibular suppressant/antiemetic

Treatment recommended for ALL patients in selected patient group

Symptoms of acute vertigo episodes can be treated with vestibular suppressants and antiemetics. Much of the effect is from the sedating action of these drugs, therefore warn patients about driving and operating equipment while being treated. Only one agent should be used at a time.

Commonly used treatments include antihistamines with anticholinergic properties (e.g., promethazine, dimenhydrinate) and antiemetics (e.g., prochlorperazine, metoclopramide, ondansetron).[34] Metoclopramide should be used for up to 5 days only to minimize the risk of neurologic and other adverse effects. It is not recommended for this indication in children.[35] 

The acute vertigo symptoms typically resolve over 72 hours.

Consider fluid and electrolyte imbalances, particularly if the patient has had prolonged nausea and vomiting. Obtaining a basic metabolic panel before and after treatment, and initiating intravenous hydration, may be necessary in these patients.

Primary options

promethazine: children ≥2 years of age: 0.25 to 1 mg/kg orally/intravenously every 4-6 hours when required, maximum 25 mg/dose; adults: 12.5 to 25 mg orally/intravenously every 4-6 hours when required

OR

dimenhydrinate: children 2-5 years of age: 12.5 to 25 mg orally every 6-8 hours when required, maximum 75 mg/day; children 6-11 years of age: 25-50 mg orally every 6-8 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 50-100 mg every 4-6 hours when required, maximum 400 mg/day

OR

prochlorperazine maleate: children 2-12 years of age and 9-13 kg: 2.5 mg orally every 12-24 hours when required, maximum 7.5 mg/day; children 2-12 years of age and 14-17 kg: 2.5 mg orally every 8-12 hours when required, maximum 10 mg/day; children 2-12 years of age and 18-39 kg: 2.5 mg orally every 8 hours when required, maximum 15 mg/day; adults: 5-10 mg orally every 6-8 hours when required, maximum 40 mg/day

OR

metoclopramide: adults: 5-10 mg orally/intravenously every 8 hours when required for a maximum of 5 days, maximum 30 mg/day

OR

ondansetron: children and adults: consult specialist for guidance on dose

ONGOING

with persistent vestibular symptoms post-treatment

1st line – vestibular rehabilitation

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ONGOING
|
with persistent vestibular symptoms post-treatment
1st line – 

vestibular rehabilitation

Physical and occupational therapy techniques are used to treat vertigo and balance disorders.[40][41]

One Cochrane review found moderate-to-strong evidence that vestibular rehabilitation is safe and effective in unilateral peripheral vestibular dysfunction. This was based on a number of high‐quality randomized controlled trials, although a quarter of the studies may have had some risk of bias due to nonblinding of outcome assessors and selective reporting.[41]

A simple home program of vestibular habituation head movement exercises reduces symptoms of imbalance during stance and gait.[41] [ Cochrane Clinical Answers logo ]

One 2015 study has demonstrated that a virtual reality-based vestibular rehabilitation program had equivalent outcomes but was more enjoyable than conventional balance exercises.[43]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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