Can benzodiazepines (BZDs) cause dizziness?

Benzodiazepines and Dizziness

Yes, benzodiazepines commonly cause dizziness as a side effect, which can increase the risk of falls, particularly in older or frail patients. 1

Mechanism and Prevalence

• Benzodiazepines cause dizziness through their central nervous system depressant effects, enhancing the activity of the inhibitory neurotransmitter GABA, which affects balance and coordination 2
• Dizziness is one of the most frequently reported adverse effects of benzodiazepines, with studies showing more than 30% of women and 6% of men reporting dizziness while taking these medications 3, 4
• The risk of dizziness may be more pronounced during initial treatment, dose increases, or when combining benzodiazepines with other central nervous system depressants 5

Specific Benzodiazepines and Dizziness

• Midazolam may cause delirium, drowsiness, dizziness, paradoxical agitation, anxiety, and insomnia as noted in clinical guidelines 1
• Lorazepam can cause drowsiness, paradoxical agitation, and dizziness, particularly when administered intravenously or subcutaneously 1
• Clonazepam can make patients sleepy or dizzy and can slow thinking and motor skills, affecting coordination especially when walking or picking things up 5

Risk Factors for Increased Dizziness

• Older age or frailty significantly increases the risk of experiencing dizziness and subsequent falls with benzodiazepine use 1, 6
• Patients with chronic obstructive pulmonary disease (COPD) or compromised respiratory function are at higher risk 1
• Concurrent use of benzodiazepines with other medications, particularly:
  • Antipsychotics (especially olanzapine) 1
  • Alcohol or other CNS depressants 5, 7
  • Opioids, which have a synergistic effect on respiratory depression and dizziness 1

Clinical Implications

• Increased risk of falls is a major concern with benzodiazepine-induced dizziness, especially in elderly patients 1, 6
• Dizziness from benzodiazepines can impair driving ability and operation of heavy machinery 5
• The sedative and dizziness effects may persist after the anxiolytic effects have worn off 1
• Benzodiazepines are not recommended for routine treatment of conditions like benign paroxysmal positional vertigo (BPPV) due to their side effects, including dizziness 1

Recommendations to Minimize Dizziness Risk

• Use the lowest effective dose, particularly in older adults or those with compromised respiratory function 1
• For older or frail patients requiring midazolam, consider reduced dosing (e.g., 0.5-1 mg subcutaneous/intravenous) 1
• For lorazepam in older or frail patients, consider lower doses (e.g., 0.25-0.5 mg) 1
• Avoid combining benzodiazepines with alcohol or other medications that may cause sleepiness or dizziness 5
• Consider short-term rather than long-term use to minimize adverse effects 1, 6
• Monitor patients for signs of excessive sedation, dizziness, and coordination problems, especially when initiating therapy 8, 5

Alternative Approaches

• For anxiety management, consider non-benzodiazepine options like quetiapine (25 mg) or hydroxyzine, which may have different side effect profiles 8
• For vertigo management, consider specific treatments based on the underlying cause rather than symptom suppression with benzodiazepines 7
• For patients requiring benzodiazepines, taking the medication at bedtime may help minimize daytime dizziness 9