From the Guidelines
There is no standard pharmacological treatment specifically recommended for benign paroxysmal positional vertigo (BPPV), and clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines 1. The primary treatment for BPPV is non-pharmacological, involving repositioning maneuvers such as the Epley maneuver. However, in some cases, medications may be prescribed to manage symptoms:
- Antihistamines: Meclizine (25-50 mg orally every 4-6 hours as needed) or dimenhydrinate (50-100 mg orally every 4-6 hours as needed) can help reduce vertigo and nausea.
- Anti-emetics: Ondansetron (4-8 mg orally every 8 hours as needed) may be used to control nausea and vomiting.
- Benzodiazepines: In severe cases, short-term use of diazepam (2-5 mg orally every 8 hours as needed) may help with acute vertigo and anxiety. These medications should be used sparingly and for short durations (typically less than a week) as they can interfere with the brain's natural compensation mechanisms and may prolong recovery, as noted in the 2017 clinical practice guideline update 1. The goal is to manage symptoms while the repositioning maneuvers take effect. It's essential to note that these medications treat symptoms but do not address the underlying cause of BPPV, which is the presence of displaced otoconia in the semicircular canals. Repositioning maneuvers remain the most effective treatment by physically moving these particles back to their proper location in the vestibule, as supported by the evidence from the 2008 clinical practice guideline 1 and the 2017 update 1. Patients should be advised that these medications may cause drowsiness and should not be taken before driving or operating machinery. They should also be informed that the medications are for short-term symptom management only and that they should continue with any prescribed repositioning exercises.
From the FDA Drug Label
MECLIZINE HYDROCHLORIDE tablets, for oral use Initial U. S. Approval: 1957 INDICATIONS AND USAGE Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults (1).
The pharmacological treatment for Benign Paroxysmal Positional Vertigo (BPPV) is meclizine. The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.
From the Research
Pharmacological Treatment for BPPV
The pharmacological treatment for Benign Paroxysmal Positional Vertigo (BPPV) is not well established, with most studies recommending non-pharmacological interventions such as the Epley maneuver or canalith repositioning procedure.
- According to 3, drug treatments are not presently recommended for BPPV, but physical therapy treatment can be very useful.
- A study by 4 compared the management of BPPV with only drugs versus drugs plus the Epley maneuver, but the results are not provided in the given text.
Non-Pharmacological Interventions
Non-pharmacological interventions, such as the Epley maneuver or canalith repositioning procedure, are the preferred treatment for BPPV.
- A study by 5 found that the canalith repositioning procedure was immediately successful in 165 patients and in 23 more patients after its repetition in a second session, resulting in a total success rate of 92.1%.
- Another study by 6 found that particle repositioning maneuvers (PRM) have a high success rate, ranging from 75% to 100% for different types of BPPV.
- A study by 7 found that canalith repositioning manoeuvres (CRP) were effective in treating PC BPPV and HC BPPV, with 91% of PC BPPV cases and 88% of HC BPPV cases being effectively treated in 2 manoeuvres or less.
Limitations of Pharmacological Treatment
The use of pharmacological treatment for BPPV is limited, and most studies recommend non-pharmacological interventions.
- According to 3, several reviews of the management of vertigo have shown that no medication in current use has well-established curative or prophylactic value or is suitable for long-term treatment.
- A study by 4 noted that the treatment of BPPV with medications such as benzodiazepines, antihistamines, and anticholinergic medications has had questionable success.