What medication can be used to treat vertigo in patients with glaucoma without exacerbating the condition?

Medications for Vertigo in Patients with Glaucoma

For patients with glaucoma suffering from vertigo, meclizine is the recommended medication as it does not exacerbate glaucoma while effectively treating vertigo symptoms. 1

First-Line Treatment Options

• Meclizine (25-50 mg every 4-6 hours as needed) is FDA-approved for the treatment of vertigo associated with vestibular system diseases and does not have contraindications related to glaucoma 1

• Avoid betahistine in glaucoma patients as it should be used with caution in patients with asthma and peptic ulcer disease, and is completely contraindicated in patients with pheochromocytoma 2

Treatment Considerations for Different Types of Vertigo

For Benign Paroxysmal Positional Vertigo (BPPV)

• Particle repositioning maneuvers should be the first-line treatment rather than medications, as they are more effective for BPPV 3
• Vestibular suppressant medications are not routinely recommended for BPPV treatment except for short-term management of severe autonomic symptoms like nausea or vomiting 3

For Ménière's Disease

• Diuretics may be considered as maintenance therapy to reduce symptoms or prevent attacks 3
• However, carbonic anhydrase inhibitor diuretics should be avoided in glaucoma patients as they can affect intraocular pressure 3
• Intratympanic steroid therapy may be offered to patients with active Ménière's disease not responsive to noninvasive treatments 3

Efficacy and Safety Considerations

• Meclizine works as an antihistamine with a suppressive effect on the central emetic center to relieve nausea and vomiting associated with vertigo 3

• Betahistine, while commonly used for vertigo in some countries, has shown mixed results in clinical trials:

  • A well-designed BEMED trial found no significant differences between betahistine and placebo in reducing vertigo attacks in Ménière's disease 3
  • However, some meta-analyses suggest betahistine may be effective for various vertiginous syndromes with an odds ratio of 3.52 compared to placebo 4, 5

• Common side effects of vestibular suppressant medications include:

  • Drowsiness, cognitive deficits, and interference with driving or operating machinery 3
  • Increased risk of falls, especially in elderly patients 3

Monitoring and Follow-up

• Patients should be reassessed within 1 month after initial treatment to document resolution or persistence of symptoms 3

• If oral medication is initiated, the patient should be monitored for improvement or stabilization of symptoms and for medication intolerance or side effects 3

• Consider titrating down or stopping the medication once symptoms subside 3

Important Precautions

• Vestibular suppressant medications are a significant independent risk factor for falls, especially in elderly patients or those taking multiple medications 3

• For patients with severe symptoms, short-term use of meclizine may be appropriate, but long-term use should be avoided due to potential side effects and interference with central compensation 3

• If vertigo symptoms persist despite appropriate medication, consider referral to a specialist for further evaluation and management 3