For acute vertigo, which is more effective, Stemetil (prochlorperazine) or Betaserc (betahistine)?

Treatment of Acute Vertigo: Stemetil (Prochlorperazine) vs Betaserc (Betahistine)

For acute vertigo, Stemetil (prochlorperazine) is more effective than Betaserc (betahistine) as an immediate treatment for symptom relief.

Mechanism and Efficacy of Each Medication

Betahistine (Betaserc)

• Betahistine is a weak H1 receptor agonist and strong H3 receptor antagonist primarily used for maintenance therapy in Ménière's disease and vestibular vertigo 1
• It works by potentially improving blood flow to the inner ear and has shown effectiveness primarily for long-term management rather than acute symptom relief 2
• The most recent high-quality evidence (BEMED trial) found no significant difference between betahistine and placebo in reducing vertigo attacks in Ménière's disease patients over a 9-month treatment period 3
• Betahistine is more suitable for preventing recurrent vertigo attacks during the intercritical phase (between acute episodes) rather than treating acute vertigo episodes 1

Prochlorperazine (Stemetil)

• Prochlorperazine is a phenothiazine antiemetic with potent anti-vertigo properties that works centrally to control acute symptoms 3
• It is more effective for immediate symptom control during acute vertigo attacks when patients are experiencing severe spinning sensations, nausea and vomiting 3
• For acute vertigo episodes, medications with direct antiemetic and anti-vertigo effects like prochlorperazine are preferred over medications like betahistine that work through vascular mechanisms 3

Clinical Application

When to Use Stemetil (Prochlorperazine):

• For acute vertigo attacks with severe symptoms requiring rapid relief 3
• When vertigo is accompanied by significant nausea and vomiting 3
• During the acute phase of Ménière's disease or vestibular neuritis 3
• For short-term management of severe vertigo symptoms 3

When to Consider Betahistine:

• For long-term maintenance therapy to reduce frequency of vertigo attacks 1, 2
• During the intercritical phase between acute episodes 1
• For patients with recurrent vertigo who need preventive therapy 2
• May be used at doses of 48 mg daily for up to 3 months for maintenance therapy 2, 4

Safety Considerations

Betahistine Safety Profile:

• Generally well-tolerated with relatively few side effects 5
• Common side effects include headache, gastrointestinal symptoms, and occasionally nasopharyngitis 3
• Should be used with caution in patients with asthma and peptic ulcer disease 3
• Contraindicated in patients with pheochromocytoma 3

Stemetil (Prochlorperazine) Precautions:

• May cause sedation and extrapyramidal side effects 3
• Should be used with caution in elderly patients and those with cardiovascular disease 3
• Not recommended for long-term use due to potential for tardive dyskinesia with prolonged use 3

Treatment Algorithm for Acute Vertigo

1. For acute severe vertigo with nausea/vomiting:

   • First-line: Stemetil (prochlorperazine) for immediate symptom control 3
   • Administer via appropriate route based on severity (oral, IM, or IV in severe cases) 3

2. After acute phase has resolved:

   • Consider betahistine for maintenance therapy to prevent recurrence 1, 2
   • Standard dosing: 48 mg daily for up to 3 months 2, 4

3. For patients with recurrent episodes:

   • Continue betahistine during intercritical phases 1
   • Keep prochlorperazine available for breakthrough acute episodes 3

Common Pitfalls to Avoid

• Mistaking betahistine for an acute treatment when it's primarily effective for prevention 1
• Using prochlorperazine for long-term management rather than acute symptom control 3
• Failing to distinguish between different causes of vertigo which may respond differently to treatment 3
• Not considering the potential side effects of prochlorperazine, particularly in elderly patients 3
• Continuing betahistine indefinitely without reassessing its effectiveness 3