What medications are used to treat vertigo?

Medications for Vertigo

Vestibular suppressant medications should NOT be used as routine treatment for benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo, as they may interfere with vestibular compensation and are less effective than repositioning maneuvers. 1, 2

First-Line Treatment for Vertigo

BPPV Management (Most Common Cause)

• Canalith Repositioning Procedures (CRPs) are the first-line treatment for BPPV with 80-90% success rate 2
  • Epley maneuver for posterior canal BPPV
  • Semont maneuver for posterior canal BPPV
  • Gufoni maneuver for horizontal canal BPPV

Medication Options (When Appropriate)

1. Meclizine (Antihistamine)

   • FDA-approved specifically for vertigo associated with vestibular system diseases 3
   • Dosage: 25 mg to 100 mg daily in divided doses
   • Cautions:
     • May cause drowsiness - avoid driving or operating machinery
     • Anticholinergic effects - use with caution in patients with asthma, glaucoma, or prostate enlargement
     • Avoid co-administration with other CNS depressants including alcohol

2. Prokinetic Antiemetics

   • Domperidone and metoclopramide
   • Useful for managing nausea and vomiting during vertigo attacks
   • Advantage: Less interference with vestibular compensation 2
   • Metoclopramide can be used under supervision in pregnant women

When to Use Medications vs. Repositioning

• For BPPV: Repositioning maneuvers (Epley, Semont, etc.) are strongly recommended as first-line treatment 1, 2
• Short-term symptom relief: Vestibular suppressants may be used temporarily while awaiting definitive treatment 2
• Non-BPPV vertigo: Medication may be more appropriate depending on underlying cause

Medication Considerations

Elderly Patients

• Require lower doses due to increased fall risk
• Vestibular rehabilitation particularly beneficial for this population 2

Medication-Induced Vertigo Risk Factors

• Renal impairment increases risk with certain medications
• Polypharmacy increases risk of vertigo as a side effect
• Aminoglycosides can cause irreversible vestibular damage 2

Pitfalls to Avoid

1. Overreliance on medications: The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine treatment of BPPV with vestibular suppressant medications 1, 2

2. Prolonged medication use: May delay central compensation and recovery

3. Missing the diagnosis: Proper diagnosis through Dix-Hallpike maneuver and HINTS examination is essential before initiating treatment 2

4. Failure to differentiate peripheral from central causes: Central vertigo requires different management and may need neuroimaging 2

Treatment Algorithm

1. Diagnose type of vertigo (BPPV vs. other causes)

   • Use Dix-Hallpike test for posterior canal BPPV
   • Use supine roll test for horizontal canal BPPV

2. For confirmed BPPV:

   • Implement appropriate repositioning maneuver based on canal involvement
   • Consider vestibular rehabilitation exercises as adjunctive therapy
   • Use medications only for short-term symptomatic relief if needed

3. For non-BPPV vertigo:

   • Meclizine 25-100 mg daily in divided doses
   • Add prokinetic antiemetics for nausea if needed
   • Consider vestibular rehabilitation

4. For medication-resistant or recurrent vertigo:

   • Reassess diagnosis
   • Consider vestibular rehabilitation
   • Evaluate for comorbidities (migraine, persistent postural perceptual dizziness)
   • Check vitamin D levels (low levels associated with recurrence)

By following this evidence-based approach, clinicians can effectively manage vertigo while minimizing unnecessary medication use and optimizing patient outcomes.