What medications can be used to treat vertigo without causing glaucoma?

Medications for Vertigo That Do Not Cause Glaucoma

For patients with vertigo who have glaucoma or are at risk for glaucoma, meclizine is the preferred first-line medication as it does not significantly affect intraocular pressure while effectively managing vertigo symptoms. 1, 2

Safe Medication Options for Vertigo in Glaucoma Patients

First-Line Options:

• Meclizine (Antivert) - an antihistamine that works by suppressing the central emetic center, should be used primarily as-needed rather than scheduled to avoid interfering with vestibular compensation 1, 2
• Dimenhydrinate (Dramamine) - similar to meclizine but may have slightly more pronounced anticholinergic effects 1, 2

Second-Line Options:

• Prochlorperazine - can be used for short-term management of severe nausea or vomiting associated with vertigo, but not recommended as primary treatment for vertigo itself 1, 3
• Short-term benzodiazepines (like lorazepam) - may be used briefly for severe symptoms with significant anxiety component, but use with caution due to fall risk 4, 1

Medications to Avoid in Glaucoma Patients

• Betahistine - should be avoided in glaucoma patients as it may potentially affect intraocular pressure 2, 4
• Carbonic anhydrase inhibitor diuretics - should be avoided as they can affect intraocular pressure 2
• Long-term vestibular suppressants - can interfere with central compensation and increase fall risk 4, 1

Treatment Approach Based on Type of Vertigo

For Benign Paroxysmal Positional Vertigo (BPPV):

• Particle repositioning maneuvers (Epley, Semont) should be first-line treatment rather than medications 4, 2
• Medications should only be used for short-term management of severe symptoms 4
• Studies show repositioning maneuvers have 78.6%-93.3% improvement compared to only 30.8% with medication alone 4

For Ménière's Disease:

• Meclizine can be used during acute attacks 1, 2
• Non-carbonic anhydrase inhibitor diuretics may be considered as maintenance therapy 2
• Intratympanic steroid therapy may be offered to patients not responsive to noninvasive treatments 4, 2

For Vestibular Neuritis:

• Short-term use of meclizine for symptomatic relief 1, 5
• Brief use of vestibular suppressants is recommended 5

Important Precautions and Monitoring

• All vestibular suppressant medications can cause drowsiness, cognitive deficits, and interference with driving 4, 1
• These medications are a significant independent risk factor for falls, especially in elderly patients 4, 1
• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 4, 2
• Consider titrating down or stopping medication once symptoms subside 4, 2
• Long-term use of vestibular suppressants can interfere with central compensation and should be avoided 1, 5

Dosing Considerations

• Meclizine: 12.5-25 mg every 4-6 hours as needed, not to exceed 100 mg daily 1, 5
• Prochlorperazine: 5-10 mg three to four times daily for short-term use only 3
• Benzodiazepines: lowest effective dose for shortest duration possible 4, 1

Remember that vestibular rehabilitation therapy is an important non-pharmacological approach that should be considered alongside medication management for most types of vertigo 4, 1.