What is the treatment for nausea and vomiting due to vertigo?

Treatment of Nausea and Vomiting Due to Vertigo

For nausea and vomiting associated with vertigo, dimenhydrinate is the first-line medication due to its FDA approval specifically for this indication, while prokinetic antiemetics like metoclopramide may be used as effective alternatives with similar efficacy. 1, 2

First-Line Pharmacological Management

Vestibular Suppressants

• Dimenhydrinate: FDA-approved specifically for prevention and treatment of nausea, vomiting, or vertigo of motion sickness 1
  • Dosage: Typically 50mg orally every 4-6 hours as needed
  • Mechanism: Acts as both an antihistamine and anticholinergic agent

Alternative First-Line Options

• Metoclopramide: Prokinetic antiemetic shown to have similar efficacy to dimenhydrinate in randomized trials 2

  • Dosage: 10mg IV or orally
  • Advantage: Less sedating than many vestibular suppressants
  • Particularly useful when nausea is a predominant symptom

• Scopolamine transdermal patch: Effective for prevention of motion sickness and associated vertigo 3

  • Apply one patch behind the ear at least 4 hours before anticipated vertigo-inducing activity
  • Each patch lasts up to 3 days
  • Particularly useful for anticipated episodes of vertigo

Treatment Based on Vertigo Etiology

For Peripheral Vertigo (e.g., BPPV, vestibular neuritis, Ménière's disease)

1. Acute symptomatic relief:

   • Short-term use of vestibular suppressants (dimenhydrinate, meclizine)
   • The American Academy of Otolaryngology-Head and Neck Surgery recommends against routine long-term use of vestibular suppressant medications for BPPV 4

2. Non-pharmacological interventions:

   • Canalith repositioning procedures (e.g., Epley maneuver) for BPPV with 80-90% success rate 4
   • Vestibular rehabilitation exercises as adjunctive therapy

For Central Vertigo (e.g., vestibular migraine, stroke)

• For vestibular migraine:
  • Triptans for acute attacks if severe 5
  • Prophylactic medications (beta-blockers, calcium channel antagonists) for frequent attacks 6

Special Considerations

Medication Administration Route

• When significant nausea/vomiting is present: Choose non-oral routes of administration 4
  • Parenteral (IV/IM) dimenhydrinate
  • Transdermal scopolamine
  • Rectal suppositories

Elderly Patients

• Use lower doses of medications due to increased risk of falls 4
• Vestibular rehabilitation is particularly beneficial for this population
• Avoid medications with strong anticholinergic effects when possible

Caution with Long-Term Use

• Prolonged use of vestibular suppressants may delay vestibular compensation 7, 6
• Limit use to acute symptomatic relief when possible

Adjunctive Measures

• Hydration: Maintain adequate fluid intake
• Position: Avoid sudden head movements during acute episodes
• Environmental modifications: Reduce sensory stimuli during acute attacks
• Vestibular rehabilitation: Particularly important for promoting long-term compensation

Treatment Algorithm

1. Identify if vertigo is peripheral or central in origin
2. For acute symptomatic relief: Start with dimenhydrinate 50mg or metoclopramide 10mg
3. If BPPV is diagnosed: Perform appropriate repositioning maneuver
4. For recurrent episodes: Consider prophylactic medication based on underlying cause
5. Implement vestibular rehabilitation for long-term management

The most recent comparative study showed that both dimenhydrinate and metoclopramide have similar efficacy in reducing nausea and vertigo symptoms, with no significant differences in side effects, making either an appropriate first-line choice 2.