What is the recommended dosage of betahistine (Betahistine) for the treatment of Benign Paroxysmal Positional Vertigo (BPPV)?

Betahistine Dosage in BPPV

Betahistine is not recommended as a routine treatment for Benign Paroxysmal Positional Vertigo (BPPV), as canalith repositioning procedures (CRPs) such as the Epley or Semont maneuver are the primary evidence-based treatments with 80-90% success rates. 1

Primary Treatment for BPPV

The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends:

1. Canalith repositioning procedures (CRPs) as first-line treatment 1
2. Vestibular rehabilitation exercises as an alternative or adjunct therapy 1
3. Against routine use of vestibular suppressant medications (including antihistamines) 1

Evidence on Betahistine in BPPV

While betahistine is not recommended as primary therapy, some research has examined its use:

• When used, the typical dosage is 48 mg daily (24 mg twice daily) for up to 3 months 2, 3
• A 2019 study found that adding betahistine (24 mg twice daily for 10 days) to repositioning maneuvers showed no superiority over repositioning maneuvers alone 4
• A 2022 study suggested betahistine as add-on therapy may provide some benefit in reducing residual symptoms after repositioning maneuvers 5

Appropriate Clinical Algorithm for BPPV Management

1. First-line treatment: Perform canalith repositioning procedure (Epley or Semont maneuver) 1
2. Follow-up: Reassess within 1 month to confirm symptom resolution 1
3. For residual symptoms after successful CRP:
   • Consider vestibular rehabilitation exercises 1
   • Betahistine may be considered for residual dizziness at 48 mg daily (24 mg twice daily) 3
4. For recurrence: Repeat CRP as needed 1

Important Considerations

• BPPV has a high recurrence risk (10-18% at 1 year, up to 36% long-term) 1
• Patient education about recognizing recurrence symptoms is essential 1
• Avoid unnecessary imaging unless diagnosis is uncertain 1
• Fall prevention strategies should be discussed, especially with elderly patients 1

Caution

• Long-term use of vestibular suppressants can delay vestibular compensation 1
• The evidence for betahistine in BPPV is limited compared to the strong evidence for repositioning maneuvers 1, 4