What medications are used to treat vertigo in Benign Paroxysmal Positional Vertigo (BPPV)?

Medications for Vertigo in BPPV

Medications should not be routinely used to treat BPPV, as canalith repositioning procedures are the first-line treatment with success rates of 90-98% when performed correctly. 1, 2

Primary Treatment Approach

• BPPV is caused by displaced calcium carbonate crystals (otoconia) in the semicircular canals of the inner ear, causing false sensations of movement 2
• The treatment of choice for posterior canal BPPV (most common type) is the Canalith Repositioning Procedure (Epley maneuver) 1, 2
• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends against routinely treating BPPV with vestibular suppressant medications 2

When Medications May Be Considered

• Vestibular suppressant medications may be used only for short-term management of severe vertigo symptoms, particularly when:
  • Patients have severe nausea or vomiting during acute episodes 2, 1
  • Patients cannot immediately undergo repositioning maneuvers due to mobility issues 2
  • Symptoms are particularly distressing while awaiting definitive treatment 3

Types of Medications Sometimes Used

• Antihistamines: May provide temporary symptomatic relief

  • Meclizine (12.5-25 mg every 4-6 hours as needed) - FDA-approved for vertigo associated with vestibular disorders 4
  • Common side effects include drowsiness and dry mouth 4

• Benzodiazepines: Generally not recommended as they may:

  • Interfere with central compensation in peripheral vestibular conditions 2
  • Cause sedation and increase fall risk, especially in elderly patients 2, 5
  • Lead to dependence with prolonged use 2

Important Clinical Considerations

• Medications only mask symptoms and do not treat the underlying cause of BPPV 2, 1
• Vestibular suppressants may delay recovery by interfering with the brain's natural compensation mechanisms 2
• Medication use may increase the risk of falls, especially in elderly patients 5
• The American Academy of Otolaryngology-Head and Neck Surgery guidelines explicitly recommend against routine use of antihistamines or benzodiazepines for BPPV 2

Proper Management Algorithm

1. Diagnosis: Confirm BPPV with Dix-Hallpike test (posterior canal) or supine roll test (lateral canal) 2, 1

2. First-line treatment: Perform appropriate canalith repositioning maneuver 6

   • Posterior canal BPPV: Epley maneuver (90-98% success rate) 1
   • Lateral canal BPPV: Gufoni or barbecue roll maneuver (86-100% success rate) 1, 7

3. If repositioning cannot be performed immediately:

   • Consider short-term use of meclizine for severe symptoms 4
   • Schedule prompt follow-up for definitive repositioning treatment 2

4. For treatment failures:

   • Reassess for correct diagnosis and canal involvement 1
   • Consider vestibular rehabilitation exercises as adjunctive therapy 5
   • Evaluate for other vestibular disorders if symptoms persist 2

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers is a major pitfall 1, 3
• Prolonged use of vestibular suppressants can delay recovery and increase side effects 2
• Failing to reassess patients after initial treatment (follow-up within 1 month is recommended) 2
• Missing canal conversions or multiple canal involvement can lead to treatment failure 1, 7

Special Considerations for Elderly Patients

• Elderly patients with BPPV may benefit from a combined approach of repositioning maneuvers followed by vestibular rehabilitation if symptoms persist 5
• Medication side effects are more pronounced in elderly patients, increasing fall risk 5
• Daily follow-up with repositioning maneuvers may provide faster relief than weekly treatment, especially in complex cases 7