What are the medications and dosages used to treat acute peripheral vertigo?

Medications for Treating Acute Peripheral Vertigo

Meclizine is the first-line medication for acute peripheral vertigo, with a recommended dosage of 25-100 mg daily in divided doses. 1

First-Line Medications

Antihistamines

• Meclizine (Antivert)
  • Dosage: 25-100 mg daily in divided doses 1
  • Administration: Oral tablets that must be swallowed whole
  • Note: May cause drowsiness; patients should avoid driving, operating machinery, and consuming alcohol 1

Dopamine Receptor Antagonists

• Prochlorperazine
  • Dosage: 5-10 mg orally or IM every 6-8 hours 2
• Metoclopramide
  • Dosage: 10 mg IM once or twice daily 3
  • Note: Useful as both antiemetic and prokinetic agent

Benzodiazepines

• Diazepam
  • Dosage: 5-10 mg orally or IM once or twice daily 3, 4
  • Note: As effective as meclizine in emergency department settings 4
  • Caution: May delay vestibular compensation; use for shortest duration possible

Second-Line/Adjunctive Medications

5-HT3 Receptor Antagonists

• Ondansetron
  • Dosage: 4-8 mg IV/oral every 8 hours 2, 5
  • Note: Superior for controlling nausea but may require more frequent readministration than other options 5

Combination Therapies

• Cinnarizine/Dimenhydrinate combination
  • Dosage: 20 mg cinnarizine/40 mg dimenhydrinate three times daily 6
  • Note: Shown to be more effective than betahistine in reducing vertigo symptoms and associated vegetative symptoms 6

Special Considerations

Patient Positioning

• During acute attacks, patients should lie on their healthy side with head and trunk raised 20 degrees 3
• Room should be quiet but not darkened 3

Medication Selection Algorithm

1. For mild-moderate vertigo with minimal nausea:

   • Start with meclizine 25-50 mg orally

2. For severe vertigo with significant nausea/vomiting:

   • Use dopamine receptor antagonists (prochlorperazine or metoclopramide)
   • Consider adding ondansetron for persistent nausea

3. For severe anxiety with vertigo:

   • Consider diazepam 5-10 mg
   • Note: Use with caution due to potential for delaying vestibular compensation

4. For refractory cases:

   • Consider combination therapy with antihistamine plus benzodiazepine
   • Try cinnarizine/dimenhydrinate combination if available

Important Precautions

• Anticholinergic effects: Use meclizine with caution in patients with asthma, glaucoma, or prostate enlargement 1
• Sedation: Most vestibular suppressants cause drowsiness; warn patients about driving and operating machinery 1
• Duration of therapy: Limit vestibular suppressant use to shortest duration necessary to avoid interfering with central compensation 2, 7
• Pregnancy considerations: Metoclopramide can be used under supervision in pregnant women 2

Adjunctive Treatments

• Vestibular rehabilitation: Should be initiated once acute symptoms are controlled 2
• Canalith repositioning procedures: For BPPV (e.g., Epley maneuver), with 80-90% success rate after 1-2 treatments 2

Remember that while medications help manage symptoms, identifying and treating the underlying cause of peripheral vertigo is essential for long-term management and preventing recurrence.