Clearly the management of central vestibular disorders depends on the diagnosis. A simple separation into peripheral and central vestibular dysfunction is not always possible, as alluded to earlier. Some patients have inadequate central compensation for a peripheral vestibular abnormality and thus remain symptomatic. In such patients, medical therapy for peripheral vestibular dysfunction, as described earlier, may prove quite effective. When a specific diagnosis, for example, postural hypotension secondary to diabetic peripheral neuropathy is made, attention should be directed to treatment of the primary condition. Severe postural hypotension is notoriously difficult to manage. In general, the approach is to use agents that increase vasoconstriction, or others which prevent vasodilatation, or drugs which might increase cardiac output. Plasma volume may be increased by the use of mineralocorticoids such as fludrocortisone acetate, but they should be prescribed cautiously.

The patient who is diagnosed as having primary CNS disease, whether it be brainstem infarction or spinocerebellar degeneration, must be managed as would be a patient without the accompanying symptoms of disequilibration. Medical therapy of vertebrobasilar ischemia is directed at preventing new infarctions, primarily with antiplatelet agents and, on rare occasions, anticoagulation. Cerebellar dysfunction, not caused by tumor, may be treated symptomatically. Vestibular suppressant medication may add a modicum of improvement, and agents helpful in the therapy of essential tremor, such as beta blocking drugs or primidone, may result in modest symptomatic improvement.

Therapy for systemic conditions producing vertigo is also dependant on the diagnosis. If systemic drug therapy, as with benzodiazepines, is actually the cause of disequilibration, then of course alteration in the medical regimen may prove efficacious. Withdrawal of all drugs, be they anticonvulsants or benzodiazepines, must proceed with caution to avoid precipitating the effects of withdrawal.

Surgical Therapy 

Surgical therapy is primarily directed toward removal of the tumors, which can affect the peripheral or central vestibular apparatus. A variety of destructive procedures for removal of the semicircular canals or section of the vestibular nerve have been utilized for intractable vertigo, particularly in Meniere's disease. Description of these procedures is beyond the scope of this Chapter and may be found in texts on Otology, Otolaryngology and Neuro-Otology.