What are the alternatives to Cinnarizine (Rizatriptan) for treating vertigo and cerebral hypoperfusion?

From the Guidelines

Alternatives to Cinnarizine for treating vertigo and cerebral hypoperfusion include canalith repositioning procedures, vestibular rehabilitation, and observation with follow-up, as these methods have shown to be more effective and safer than vestibular suppressant medications. According to the clinical practice guideline for benign paroxysmal positional vertigo (BPPV) update 1, vestibular suppressant medications such as antihistamines and/or benzodiazepines are not recommended for routine treatment of BPPV due to the potential for significant harm, including drowsiness, cognitive deficits, and increased risk of falls.

Key Points to Consider

• The guideline recommends against the use of vestibular suppressant medications for BPPV treatment, except in cases of severely symptomatic patients or those requiring prophylaxis for canalith repositioning procedures 1.
• Canalith repositioning procedures, such as the Epley maneuver, have been shown to be effective in treating BPPV, with success rates ranging from 78.6% to 93.3% 1.
• Vestibular rehabilitation, either self-administered or with a clinician, may also be offered as a treatment option for BPPV 1.
• Observation with follow-up is another recommended approach, as some patients may experience spontaneous resolution of symptoms over time 1.

Important Considerations for Treatment

• Patients with BPPV should be assessed for factors that modify management, including impaired mobility or balance, central nervous system disorders, and increased risk for falling 1.
• Clinicians should educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up 1.
• The role of patient preferences in making decisions deserves further clarification, and clinicians should provide patients with clear and comprehensible information on the benefits and risks of different treatment options 1.

Recent Guidelines and Recommendations

• The 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage suggests that consistent administration of nimodipine is recommended, even in the setting of nimodipine-induced hypotension, as it may help reduce the incidence of delayed cerebral ischemia (DCI) 1. However, this guideline is not directly related to the treatment of vertigo and cerebral hypoperfusion.

In summary, the most effective and safest alternatives to Cinnarizine for treating vertigo and cerebral hypoperfusion are canalith repositioning procedures, vestibular rehabilitation, and observation with follow-up, as recommended by the clinical practice guideline for BPPV update 1.

From the Research

Alternatives to Cinnarizine for Treating Vertigo and Cerebral Hypoperfusion

• Betahistine is an alternative to cinnarizine for treating vertigo, as seen in studies 2, 3, where it was used as a reference therapy.
• Dimenhydrinate, often used in combination with cinnarizine, can also be considered as an alternative, as shown in studies 4, 3, where the fixed combination of cinnarizine and dimenhydrinate was compared to monotherapies.
• Antiplatelet therapy, reduction of risk factors, and a healthy lifestyle are also important in managing vertebrobasilar insufficiency, as mentioned in study 5.
• Systemic anticoagulation, endovascular revascularization, and bypass surgery may be indicated in selected cases, as discussed in study 5.

Efficacy of Alternatives

• Betahistine was found to be less effective than the fixed combination of cinnarizine and dimenhydrinate in reducing vertigo symptoms, as seen in studies 2, 3.
• Dimenhydrinate, when used alone, was also found to be less effective than the fixed combination, as shown in study 4.
• The fixed combination of cinnarizine and dimenhydrinate was found to be effective in reducing vertigo symptoms, as seen in studies 2, 4, 3, 6.

Tolerability of Alternatives

• Betahistine was found to have a similar tolerability profile to the fixed combination of cinnarizine and dimenhydrinate, as seen in study 3.
• Dimenhydrinate, when used alone, was found to have a similar tolerability profile to the fixed combination, as shown in study 4.
• The fixed combination of cinnarizine and dimenhydrinate was found to be well-tolerated, as seen in studies 2, 4, 3, 6.