What is the recommended medication for an acute attack of vertigo?

Medication Management for Acute Vertigo Attacks

For acute attacks of vertigo, vestibular suppressants such as meclizine (25-100 mg daily in divided doses) are indicated as the first-line pharmacological treatment, though they should be limited to short-term use (<1 week) to avoid interference with vestibular compensation. 1, 2

First-Line Pharmacological Options

Meclizine (First Choice)

• Dosage: 25-100 mg daily in divided doses 1
• Mechanism: Antihistamine with anticholinergic properties that suppresses vestibular symptoms
• FDA approved: Specifically indicated for "treatment of vertigo associated with diseases affecting the vestibular system in adults" 1
• Administration: Oral tablets (12.5 mg, 25 mg, 50 mg) to be swallowed whole 1

Important Cautions with Meclizine

• May cause drowsiness - patients should use caution when driving or operating machinery 1
• Potential anticholinergic effects - use with care in patients with asthma, glaucoma, or prostate enlargement 1
• Common side effects include drowsiness, dry mouth, headache, fatigue, and vomiting 1

Alternative Medications

Antiemetics as Adjuncts

• Prokinetic antiemetics (domperidone, metoclopramide) are useful adjuncts for patients experiencing nausea/vomiting during vertigo attacks 3

Benzodiazepines

• Diazepam has shown similar efficacy to meclizine in treating acute peripheral vertigo 4
• However, benzodiazepines should be used cautiously due to sedation and potential for dependency

Important Considerations

Limiting Duration of Vestibular Suppressants

• The American Academy of Otolaryngology-Head and Neck Surgery recommends that vestibular suppressants should NOT be used routinely as they can:
  • Interfere with vestibular compensation
  • Cause adverse effects and medication interactions
  • Decrease diagnostic sensitivity 2
• Limit use to short-term (<1 week) to avoid interference with vestibular compensation 2

Non-Pharmacological Approaches

• For Benign Paroxysmal Positional Vertigo (BPPV):
  • Canalith repositioning procedures (CRPs) are more effective than medications
  • Success rates of 80-96% with just 1-3 treatments 2
  • Specific maneuvers include Epley (90.7% success rate), Gufoni (93% success rate), and Barbecue Roll (75-90% effectiveness) 2

Treatment Algorithm for Acute Vertigo

1. Determine if positional or spontaneous vertigo

   • If positional (symptoms triggered by head movement) → Consider BPPV and use repositioning maneuvers
   • If spontaneous → Proceed with medication

2. First-line medication for acute spontaneous vertigo

   • Meclizine 25-50 mg orally (can repeat every 4-6 hours as needed, not exceeding 100 mg daily) 1

3. For significant nausea/vomiting

   • Add prokinetic antiemetic (metoclopramide 10 mg) 3

4. If symptoms persist or are severe

   • Consider short-term benzodiazepine (diazepam 5-10 mg) 4
   • Ondansetron may be beneficial for nausea but less effective for vertigo itself 5

5. Patient positioning and environment

   • Have patient lie on their healthy side with head and trunk raised 20 degrees 6
   • Keep room quiet but not darkened 6

Pitfalls to Avoid

1. Prolonged use of vestibular suppressants

   • Can delay central compensation and recovery 2
   • Limit to <1 week

2. Overlooking BPPV

   • Medications are less effective than repositioning maneuvers for BPPV 7
   • Perform Dix-Hallpike test to diagnose posterior canal BPPV 7

3. Unnecessary imaging

   • Brain imaging is not recommended for typical vertigo presentations without neurological signs 7
   • Consider MRI only if central causes are suspected or symptoms persist despite treatment 2

4. Ignoring red flags

   • Abnormal HINTS examination, neurological deficits, first episode of severe vertigo in elderly or those with vascular risk factors require further evaluation 2