What medications are used to treat Benign Paroxysmal Positional Vertigo (BPPV)?

Medications for Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) should be the primary treatment for BPPV, not medications, as they have 80-90% success rates with 1-2 treatments and address the underlying cause of the condition. 1, 2

Primary Treatment Approach

Medications have a limited role in BPPV management and should not be considered first-line therapy. Here's why:

1. Repositioning Maneuvers vs. Medications:

   • The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends physical therapy through canalith repositioning procedures as the primary evidence-based treatment 1, 2
   • Specific maneuvers based on canal involvement:
     • Posterior canal (most common, 88%): Epley or Semont maneuvers
     • Horizontal canal (10%): Gufoni maneuver or Barbeque roll
     • Anterior canal (2%): Deep head hanging maneuvers 3, 4

2. When Medications May Be Considered:

   • Short-term symptom management during acute vertigo attacks
   • For patients who cannot undergo repositioning maneuvers
   • As adjunctive therapy when repositioning is delayed

Medication Options When Needed

When medications are used (as a temporary measure only), options include:

1. Vestibular Suppressants:

   • Antihistamines (e.g., meclizine) 2, 5
   • Benzodiazepines (short-term use only) 2
   • Dopamine receptor antagonists (e.g., prochlorperazine, metoclopramide) 2

2. Anti-nausea Medications:

   • Prokinetic antiemetics (domperidone, metoclopramide) can help manage associated nausea without significantly interfering with vestibular compensation 2
   • 5-HT3 antagonists (e.g., ondansetron) may be considered 2

Important Clinical Considerations

• Medication Limitations: Vestibular suppressants may temporarily relieve symptoms but do not treat the underlying cause of BPPV (displaced otoconia) 6

• Medication Risks: Vestibular suppressants can cause drowsiness, cognitive impairment, and may delay central compensation mechanisms 6

• Contraindications: Elderly patients are particularly susceptible to side effects of vestibular suppressants, including increased fall risk 2, 6

• Duration of Use: If medications are used, they should be limited to short-term use (days, not weeks) to avoid dependence and interference with natural recovery 2

Clinical Algorithm for BPPV Management

1. Diagnosis: Confirm BPPV with appropriate provocative testing (Dix-Hallpike or Roll test)

2. First-line Treatment: Perform appropriate canalith repositioning procedure based on canal involvement

3. Medication Role: Consider vestibular suppressants only if:

   • Patient cannot immediately undergo repositioning
   • Symptoms are severe and intolerable while awaiting repositioning
   • Patient has contraindications to repositioning maneuvers

4. Follow-up: Reassess within 1 month to confirm resolution 2

Common Pitfalls to Avoid

• Overreliance on Medications: Many emergency departments treat BPPV with vestibular suppressants like meclizine rather than performing repositioning maneuvers, which is contrary to evidence-based guidelines 6

• Unnecessary Imaging: Brain imaging is often ordered but not recommended by guidelines for typical BPPV 6

• Prolonged Medication Use: Extended use of vestibular suppressants can delay recovery and central compensation 2, 6

• Missing Recurrences: BPPV has a significant recurrence rate (approximately 15%), especially in elderly patients and those with head trauma or vestibular neuropathy 7

The evidence overwhelmingly supports repositioning maneuvers as the definitive treatment for BPPV, with medications playing only a supportive, temporary role when necessary.