What medications can be tried in the Emergency Department (ED) for vertigo (room spinning)?

From the Guidelines

For patients experiencing room spinning (vertigo) in the emergency department, the most effective treatment approach is to use vestibular suppressants and antiemetics only for short-term management of severe symptoms, with a focus on repositioning maneuvers as the primary treatment for benign paroxysmal positional vertigo (BPPV) 1. The use of medications such as diazepam, lorazepam, or meclizine may be considered for short-term relief of vertigo symptoms, but they should not be used as a routine treatment for BPPV due to the lack of evidence supporting their effectiveness and the potential for harm, including drowsiness, cognitive deficits, and increased risk of falls 1. Some key points to consider when treating vertigo in the emergency department include:

• The importance of diagnosing the underlying cause of vertigo, with BPPV being a common and treatable condition 1
• The use of repositioning maneuvers, such as the Epley maneuver, as a first-line treatment for BPPV, with a high success rate and minimal side effects 1
• The potential benefits and risks of using vestibular suppressants and antiemetics, including the risk of dependence and increased risk of falls 1
• The importance of limiting treatment to the shortest duration possible and advising patients about potential sedation and the need to avoid driving while taking these medications 1 Overall, the goal of treatment for vertigo in the emergency department should be to provide short-term relief of symptoms while also addressing the underlying cause of the condition, with a focus on repositioning maneuvers as the primary treatment for BPPV.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Medications for Room Spinning in the Emergency Department

• Diazepam and meclizine are two oral medications commonly used to alleviate symptoms of vertigo in the emergency department 2.
• A study found that diazepam and meclizine are equally effective in the treatment of patients with peripheral vertigo in the ED, with no significant difference in mean improvements in vertigo symptoms between the two groups 2.
• Meclizine is also used to treat benign paroxysmal positional vertigo (BPPV), but current guidelines recommend performing a bedside test (Dix-Hallpike test) and treating patients with a bedside positional (Epley) maneuver instead of using vestibular suppressant medications like meclizine 3.

Alternative Approaches

• The Dix-Hallpike test is a simple bedside test that can reliably diagnose BPPV in patients with acute onset dizziness or vertigo, but it is often underutilized and misused in the emergency department 4.
• A practical approach for emergency physicians is to perform the Dix-Hallpike test and then treat patients with the Epley maneuver, which can reduce resource utilization, ED length of stay, and use of ineffective medications 3.

Physiological Effects of Antivertigo Medications

• Meclizine, an antivertigo antihistamine, has been shown to have physiological and behavioral effects in adults, including changes in distortion-product otoacoustic emissions, auditory brainstem response, and quantitative electroencephalography 5.
• The use of antihistamines like meclizine may have implications for vestibular rehabilitation and improving performance in learning-disordered children, but caution is advised due to potential side effects 5.