What medications can help with nausea and dizziness caused by Benign Paroxysmal Positional Vertigo (BPPV)?

Medication Management for Nausea and Dizziness in BPPV

Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines as they may interfere with central compensation and provide little therapeutic benefit. 1, 2

First-Line Approach: Non-Pharmacological Management

The primary treatment for BPPV should focus on canalith repositioning procedures (CRPs) rather than medications:

• Epley maneuver: 90.7% success rate after initial attempt, increasing to 96% after second attempt 2
• Other effective maneuvers include:
  • Gufoni Maneuver (93% success for geotropic type BPPV)
  • Barbecue Roll/Lempert Maneuver (75-90% effective for lateral canal BPPV)
  • Self-administered Epley (64% improvement rate)

Medication Considerations for Symptom Management

When medications are considered for managing associated symptoms:

For Nausea/Vomiting:

• Prokinetic antiemetics (domperidone, metoclopramide) may be useful adjuncts for managing nausea/vomiting during vertigo attacks 2
• These target the nausea without significantly interfering with vestibular compensation

Medications to Avoid:

• Vestibular suppressants including:
  • Antihistamines (meclizine, diphenhydramine)
  • Benzodiazepines (diazepam, clonazepam)
  • Anticholinergics (scopolamine)

These medications are explicitly not recommended by guidelines because they:

1. Interfere with central compensation mechanisms 1, 2
2. Provide minimal therapeutic benefit 3
3. May cause significant side effects, particularly in elderly patients 2

Evidence on Medication Efficacy

A 2023 systematic review and meta-analysis found that:

• Vestibular suppressants may have no effect on symptom resolution at follow-up
• CRPs were superior to medications for symptom resolution
• Vestibular suppressants had uncertain effects on symptom resolution within 24 hours, repeat ED/clinic visits, patient satisfaction, and quality of life 3

Special Considerations

Elderly Patients:

• Higher risk of medication side effects
• May require lower doses if medications are absolutely necessary
• At increased risk of falls with untreated vestibular disorders 2

Duration of Treatment:

• If medications are used for severe symptoms, they should be limited to the shortest duration possible
• Brief use of vestibular suppressants may be considered in severe cases, but should be discontinued as soon as possible 4

Common Pitfalls to Avoid

1. Prolonged medication use: Extended use of vestibular suppressants can delay recovery by interfering with central compensation mechanisms
2. Relying solely on medications: Evidence strongly supports CRPs as the primary treatment for BPPV
3. Overlooking non-pharmacological approaches: Vestibular rehabilitation exercises can be effective adjuncts or alternatives when CRPs fail 2
4. Failing to reassess: Patients should be reassessed within 1 month to document resolution or persistence of symptoms 2

In summary, the management of nausea and dizziness in BPPV should focus primarily on canalith repositioning procedures rather than medications. If medications are needed for symptom management, prokinetic antiemetics may be considered for nausea, while vestibular suppressants should generally be avoided.