Is diazepam (Diazepam) suitable for treating symptoms of benign positional vertigo (BPV)?

Diazepam is Not Recommended for Benign Positional Vertigo Treatment

Diazepam should not be used for routine treatment of benign paroxysmal positional vertigo (BPPV) as it provides no additional benefit over canalith repositioning procedures and may cause harmful side effects. 1, 2

Evidence Against Diazepam Use in BPPV

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine treatment of BPPV with vestibular suppressant medications such as benzodiazepines (including diazepam) 1, 2. This recommendation is based on:

• Grade C evidence from observational and cross-sectional studies
• A preponderance of benefit over harm in avoiding these medications
• No evidence in the literature suggesting that vestibular suppressant medications are effective as definitive treatment for BPPV 1

Clinical trials have shown:

• Diazepam showed no additional relief compared to placebo in controlled trials 1
• Medication-alone treatment arms showed substantially lower improvement rates (30.8%) compared to repositioning maneuvers (78.6%-93.3%) 1
• Patients who underwent repositioning maneuvers alone recovered faster than those who received both maneuvers and vestibular suppressants 1

Potential Harms of Diazepam in BPPV

Benzodiazepines like diazepam carry significant risks:

• Drowsiness and cognitive deficits
• Interference with driving or operating machinery
• Significant independent risk factor for falls, especially in older adults 1
• Potential for polypharmacy complications
• May interfere with vestibular compensation and natural recovery 3
• Can mask symptoms during diagnostic maneuvers, potentially leading to misdiagnosis 1

First-Line Treatment for BPPV

The evidence-based approach to BPPV management includes:

1. Canalith repositioning procedures (CRPs) as first-line therapy 2, 4

   • Epley maneuver is most effective for posterior canal BPPV (80-90% success rate)
   • Semont and Gufoni maneuvers are also effective options 4

2. Vestibular rehabilitation exercises as adjunctive therapy or when CRPs fail 2, 4

   • May decrease recurrence rates, especially in elderly patients

Limited Exceptions

There may be a very small subgroup of patients who might benefit from short-term vestibular suppression with medications like diazepam 1:

• Patients with severe, intractable symptoms who refuse other treatment options
• Patients requiring prophylaxis for CRP
• Patients with significant psychological anxiety secondary to BPPV 1

However, even in these cases, the most recent evidence from a 2023 systematic review and meta-analysis of randomized controlled trials found that vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up 5.

Clinical Algorithm for BPPV Management

1. Diagnose BPPV using appropriate maneuvers (Dix-Hallpike)
2. Perform appropriate canalith repositioning procedure based on the affected canal
3. Consider vestibular rehabilitation exercises, especially for elderly patients
4. For nausea/vomiting, consider prokinetic antiemetics (domperidone, metoclopramide) that don't interfere with vestibular compensation 2
5. Only consider diazepam in extremely limited circumstances for severe symptoms when other approaches have failed or are refused

Remember that diazepam and other vestibular suppressants may delay natural compensation and recovery from BPPV while adding potential risks of sedation and falls.