What are the recommended medications for treating vertigo?

Recommended Medications for Treating Vertigo

For vertigo treatment, medications should NOT be used routinely as first-line therapy, especially for BPPV, as canalith repositioning procedures (CRPs) are the primary recommended treatment. 1

Understanding Vertigo and Its Causes

Vertigo can be classified into:

• Peripheral vertigo: Inner ear origin (BPPV, Ménière's disease, vestibular neuritis)
• Central vertigo: Brainstem/cerebellum origin (stroke, migraine-associated vertigo)

The medication approach differs based on the underlying cause and presentation pattern.

Medication Options by Vertigo Type

1. Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith repositioning procedures (CRPs) - NOT medications 1
• Medications: Generally NOT recommended for routine BPPV management 1
  • Vestibular suppressants should be avoided as they may interfere with natural compensation 1

2. Vestibular Neuritis

• Acute phase: Brief use of vestibular suppressants only 1, 2
  • Meclizine 25-100 mg daily in divided doses 3
  • Diazepam 5 mg (equally effective as meclizine for acute vertigo) 4

3. Ménière's Disease

• Preventive: Salt restriction and diuretics 2
• During attacks: Vestibular suppressants
  • Anticholinergics
  • Antihistamines (meclizine)
  • Benzodiazepines (short-term use) 2

4. Migraine-Associated Vertigo

• Prophylactic agents are the mainstay of treatment 2:
  • L-channel calcium channel antagonists
  • Tricyclic antidepressants
  • Beta-blockers

5. Psychogenic Vertigo

• Benzodiazepines may be most useful 2

Specific Medication Classes for Vertigo

Antihistamines

• Meclizine (Antivert): 25-100 mg daily in divided doses 3
  • FDA-approved specifically for vertigo associated with vestibular system diseases
  • Common side effects: drowsiness, dry mouth, blurred vision 3
  • Caution: May cause drowsiness; use care when driving or operating machinery 3

Benzodiazepines

• Diazepam: 5 mg shown to be equally effective as meclizine for acute vertigo 4
• Useful for both vestibular suppression and anxiety component of vertigo 2
• Caution: Risk of dependence with prolonged use

Anticholinergics

• Help reduce vertigo symptoms
• Caution: Should be prescribed carefully to patients with history of asthma, glaucoma, or prostate enlargement 3

Antiemetics

• Prokinetic antiemetics (domperidone, metoclopramide)
  • Useful adjuncts for managing nausea and vomiting during vertigo attacks
  • Don't significantly interfere with vestibular compensation 1

Important Considerations

• Drug interactions: Meclizine and other CNS depressants (including alcohol) may increase CNS depression when used together 3
• Elderly patients: Require lower medication doses to avoid adverse effects and are at higher risk of falls 1
• Duration of therapy: Most vestibular suppressants should be used short-term only, as they may interfere with natural vestibular compensation 1, 2
• Adjunctive therapy: Vestibular rehabilitation exercises may be beneficial, especially when medications fail 1

Common Pitfalls to Avoid

1. Overuse of vestibular suppressants: These medications should be used briefly during acute symptoms, not long-term 1, 2
2. Neglecting the underlying cause: Treatment should address the specific type of vertigo, not just symptoms 2, 5
3. Failing to consider non-pharmacological approaches: CRPs for BPPV and vestibular rehabilitation are often more effective than medications 1
4. Medication interactions: Be aware of potential interactions between vertigo medications and CYP2D6 inhibitors 3

Remember that the goal of vertigo treatment is not just symptom suppression but addressing the underlying cause to reduce morbidity, improve quality of life, and prevent recurrence.