Intended for healthcare professionals

Practice Change

Chronic vertigo: treat with exercise, not drugs

BMJ 2017; 358 doi: (Published 23 August 2017) Cite this as: BMJ 2017;358:j3727
  1. Vincent A van Vugt, GP registrar and PhD student1,
  2. Henriëtte E van der Horst, professor of general practice1,
  3. Rupert A Payne, consultant senior lecturer in primary health care2,
  4. Otto R Maarsingh, general practitioner and senior researcher1
  1. 1Department of General Practice & Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Centre, 1081 BT Amsterdam, The Netherlands
  2. 2Centre for Academic Primary Care, University of Bristol, UK
  1. Corresponding author: V A van Vugt v.vanvugt{at}

What you need to know

  • Patients with vertigo should first be treated with any specific treatment for the underlying vestibular disease

  • Vestibular rehabilitation is a form of exercise therapy designed to optimise the process of vestibular compensation that is disrupted in patients with chronic vertigo

  • Patients with chronic vertigo who do not respond to disease-specific treatments should be offered vestibular rehabilitation instead of anti-vertigo drugs

Chronic vertigo is a challenging problem. Currently patients are generally treated in general practice with betahistine (off-label use), while stronger evidence exists for the effectiveness of vestibular rehabilitation.

Vertigo is the most common type of dizziness.1 Each year around 1 in 20 people in the general population experiences vertigo.2 Around 80% of these people affected by vertigo find that it severely impairs their daily functioning.2 Since the symptoms of vertigo prevent many people from working, as well as resulting in an increase in the risk of falling and a high use of healthcare services, vertigo also represents a substantial economic cost.2

Most cases of vertigo are caused by peripheral vestibular disorders such as vestibular neuronitis, benign paroxysmal positional vertigo, vestibular migraine, and Ménière’s disease.2 Initial treatment varies, depending on the most likely vestibular disorder. Box 1 provides an overview of specific treatments for the most common peripheral vestibular disorders.

Box 1: Specific treatments for the most common peripheral vestibular disorders

Vestibular neuronitis
  • There is no known curative treatment for vestibular neuronitis; evidence for the effectiveness of treatment with corticosteroids is insufficient3

  • Symptomatic treatment with vestibular suppressant medications (anticholinergics, antihistamines, and benzodiazepines) and antiemetics can be given in the acute phase of vestibular neuronitis.4 However, these drugs should not be prescribed for longer than three days5 6 because they can be counterproductive due to suppression of vestibular compensation4

  • Vestibular rehabilitation is indicated if the patient experiences chronic vertigo7

Benign paroxysmal positional vertigo (BPPV)
  • Patients suspected of posterior canal BPPV …

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