What medications can cause vertigo?

Medications That Can Cause Vertigo

Several medication classes can cause vertigo as an adverse effect, with aminoglycosides (particularly streptomycin), cycloserine, and certain anticonvulsants being among the most common culprits. 1, 2

Major Drug Classes Associated with Vertigo

Antibiotics

• Aminoglycosides:
  • Streptomycin: Causes irreversible damage to the vestibular branch of the eighth cranial nerve, leading to vertigo, ataxia, nystagmus, and sometimes hearing loss 1
  • Gentamicin: Can cause severe unilateral or bilateral vestibular loss 3
  • Risk increases when combined with other ototoxic drugs 1

Anti-tuberculosis Drugs

• Cycloserine: Causes dose-related central nervous system effects including vertigo, especially in doses >500 mg/day and in alcoholics 1
• Ethambutol: May occasionally cause peripheral neuritis which can manifest with balance issues 1

Vestibular Suppressants (paradoxically can cause vertigo, especially upon withdrawal)

• Anticholinergics (e.g., scopolamine): Can cause blurred vision, dry mouth, urinary retention, and sedation 2
• Benzodiazepines: Carry significant risk for dependence; withdrawal can worsen vertigo 2

Cardiovascular Medications

• Calcium channel blockers: While sometimes used to treat vestibular migraine, they can paradoxically cause dizziness 4
• Anti-hypertensives: Can cause vertigo through blood pressure fluctuations 5

Neuropsychiatric Medications

• Anti-convulsants: Commonly associated with vertigo/dizziness 5
• Anti-depressants: Can cause dizziness as a side effect 5
• Anti-psychotics: May induce vertigo in some patients 5

Other Medications

• NSAIDs and other anti-inflammatory drugs: Reported to cause vertigo 5
• Alcohol: Ethanol-induced vertigo is common 2

Mechanisms of Drug-Induced Vertigo

1. Direct ototoxicity: Damage to inner ear structures (aminoglycosides)
2. CNS effects: Affecting central vestibular pathways (cycloserine, anticonvulsants)
3. Hemodynamic effects: Blood pressure changes affecting cerebral perfusion (antihypertensives)
4. Neurotransmitter modulation: Affecting balance-related neurotransmitter systems 6

Risk Factors for Drug-Induced Vertigo

• Renal impairment: Increases risk with aminoglycosides and cycloserine 1
• Advanced age: Elderly patients are more susceptible to medication side effects 2
• Polypharmacy: Combination of multiple potentially ototoxic medications 1
• Pre-existing vestibular disorders: Increased sensitivity to vestibular side effects

Clinical Pearls and Pitfalls

• Monitoring: For high-risk medications like aminoglycosides, monitor for early symptoms of vertigo, headache, vomiting, and tinnitus 1
• Dose adjustment: Reduce aminoglycoside dosage by 50% if vertigo or other ototoxic symptoms occur 1
• Medication history: Always consider medication-induced vertigo in patients with new-onset balance problems, especially following hospitalization 3
• Delayed recognition: Many patients don't associate their vertigo with medication use - only 4 of 18 patients in one study knew they had received gentamicin before developing symptoms 3
• Vestibular rehabilitation: Physical therapy can help patients compensate for medication-induced vestibular damage 2

Special Populations

• Elderly: Require lower doses of vestibular suppressants due to higher fall risk 2
• Pregnancy: Most antiemetics should be avoided; metoclopramide can be used under supervision 2
• Renal impairment: Requires dose adjustment or avoidance of aminoglycosides and cycloserine 1

Remember that medication-induced vertigo can significantly impact quality of life and increase fall risk, particularly in elderly patients. Prompt recognition and management are essential to prevent complications and improve outcomes.