Can escitalopram (SSRI) be used to treat anxiety in a patient with vertigo (giddiness of the head), starting at a low dose?

Escitalopram for Anxiety with Vertigo Symptoms

Escitalopram is an appropriate and potentially beneficial treatment option for anxiety with giddiness/vertigo symptoms, starting at a low dose of 10 mg daily, with caution in patients with severe renal impairment, QT prolongation, or those taking MAOIs. 1, 2

Dosing and Administration

• Starting dose: 10 mg once daily (morning or evening, with or without food) 1
• For elderly patients or those with hepatic impairment: Start with 10 mg/day 1
• After 1 week, dose may be increased to 20 mg daily if needed 1, 2
• Gradual dose reduction is recommended when discontinuing treatment to avoid withdrawal symptoms 1

Efficacy for Anxiety with Vertigo

Escitalopram is particularly suitable for this clinical scenario for several reasons:

• Escitalopram is FDA-approved for generalized anxiety disorder 1
• Research indicates escitalopram may have a beneficial effect on vertigo symptoms in patients with both anxiety and vertigo 3
• A study specifically examining patients with Meniere's disease (characterized by vertigo) and generalized anxiety disorder found that escitalopram 10 mg effectively controlled vertigo attacks 3
• Escitalopram has demonstrated efficacy in anxiety disorders with a rapid onset of action, showing significant improvement as early as 1-2 weeks 4, 2

Contraindications

Escitalopram should NOT be used in patients with:

1. Concomitant use of MAOIs or within 14 days of stopping/starting an MAOI 1
2. Known hypersensitivity to escitalopram or citalopram 1
3. Concomitant use with pimozide (Orap) due to risk of serious heart problems 1
4. Caution in patients with severe renal impairment 1
5. Caution in patients taking other medications that may prolong QT interval 5

Side Effects to Monitor

Common side effects to watch for include:

• Dizziness (5% vs 3% with placebo) - particularly relevant given the presenting complaint 1
• Nausea (15-18%) 1
• Insomnia (9-12%) 1
• Fatigue (5-8%) 1
• Sexual dysfunction (9-14% in males, 2-6% in females) 1

Special Considerations for Vertigo

• Starting at a low dose is crucial since SSRIs can initially worsen anxiety or agitation, which could exacerbate vertigo symptoms 5
• A "test dose" approach may be advisable given that anxiety/agitation can be an initial adverse effect of SSRIs 5
• Discontinuation syndrome from SSRIs can include dizziness, vertigo, and imbalance, so gradual tapering is essential if discontinuation is needed 5, 1
• Escitalopram may have the least effect on CYP450 isoenzymes compared to other SSRIs, potentially resulting in fewer drug interactions 5

Clinical Pearls

1. Morning vs. evening dosing: If drowsiness occurs, consider evening dosing; if insomnia occurs, consider morning dosing 2

2. Monitoring timeline: Assess response within 1-2 weeks of starting treatment 2

3. Therapeutic expectations: Full therapeutic effect may take 4-8 weeks, though some improvement may be seen earlier 6, 4

4. Long-term efficacy: Studies show continued improvement with long-term treatment of anxiety, with 92% of patients responding after 24 weeks of treatment 6

5. Screen for bipolar disorder before initiating treatment to avoid precipitating mania 1

Escitalopram represents an excellent choice for treating anxiety with vertigo symptoms due to its favorable side effect profile, demonstrated efficacy in anxiety disorders, and potential beneficial effects on vertigo itself 7, 3.