What is the medication treatment for Benign Paroxysmal Positional Vertigo (BPPV) in a 90-year-old female?

From the Guidelines

For a 90-year-old female with Benign Paroxysmal Positional Vertigo (BPPV), medication treatment is generally not the first-line approach, and instead, canalith repositioning procedures like the Epley maneuver performed by a healthcare provider are the most effective treatment. The use of vestibular suppressant medications is not routinely recommended for the treatment of BPPV, as they may produce significant harm, including drowsiness, cognitive deficits, and an increased risk of falls 1. If medications are needed for symptom management, consider vestibular suppressants for short-term use only (3-5 days maximum) to avoid delaying central compensation. Options include meclizine 12.5-25mg every 4-6 hours as needed, dimenhydrinate 25-50mg every 4-6 hours as needed, or diazepam 2-5mg every 8 hours as needed.

Key Considerations

• In elderly patients, start at the lowest dose to minimize side effects like sedation, confusion, and fall risk.
• These medications only mask symptoms temporarily and don't treat the underlying cause of BPPV, which involves displaced calcium carbonate crystals in the inner ear's semicircular canals.
• Long-term use should be avoided as it may delay recovery and increase fall risk, particularly concerning in a 90-year-old patient.
• Regular reassessment is essential to discontinue medications as soon as possible.

Treatment Approach

• The American Academy of Otolaryngology-Head and Neck Surgery recommends against the routine use of vestibular suppressant medications for BPPV treatment 1.
• Canalith repositioning procedures, such as the Epley maneuver, are strongly recommended as the initial treatment for posterior canal BPPV 1.
• Vestibular rehabilitation may be offered as an additional treatment option for patients with BPPV 1.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. Recommended dosage: 25 mg to 100 mg daily, in divided doses

The medication treatment for Benign Paroxysmal Positional Vertigo (BPPV) in a 90-year-old female is meclizine. The recommended dosage is 25 mg to 100 mg daily, in divided doses 2.

• Key considerations:
  • The patient's age and potential comorbidities should be taken into account when prescribing meclizine.
  • The patient should be cautioned about potential drowsiness and adverse reactions such as dry mouth, headache, and vomiting.
  • The patient should be advised to use caution when driving a car or operating dangerous machinery due to the potential for drowsiness.
• Important interactions:
  • Coadministration of meclizine with other CNS depressants, including alcohol, may result in increased CNS depression.
  • CYP2D6 inhibitors may interact with meclizine, as it is metabolized by CYP2D6.

From the Research

Medication Treatment for BPPV

The medication treatment for Benign Paroxysmal Positional Vertigo (BPPV) in a 90-year-old female is not well-established, but some studies provide insight into the effectiveness of various medications.

• Betahistine and dimenhydrinate are two medications that have been studied in the treatment of BPPV 3, 4, 5.
• A study comparing the efficacy of vestibular rehabilitation and pharmacological treatment in BPPV found that vestibular rehabilitation resulted in greater improvement in severity of vertigo, balance parameters, and vestibular dysfunction than pharmacological therapy 3.
• Another study found that betahistine and dimenhydrinate were effective in reducing symptoms of BPPV, but there was no significant difference between the two medications 4.
• A review of the pharmacological treatment of vertigo discusses the use of various medications, including anticholinergics, antihistamines, benzodiazepines, calcium channel antagonists, and dopamine receptor antagonists, but notes that drug treatments are not presently recommended for BPPV 6.
• A study evaluating the effects of betahistine and dimenhydrinate on posterior canal BPPV found that the addition of these medications to canalith repositioning maneuver did not show superiority to treatment with repositioning maneuvers alone 5.

Considerations for Elderly Patients

• A study on the treatment of BPPV in the elderly found that vestibular habituation training (VHT) was effective in reducing symptoms of vertigo, albeit with a slower therapeutic effect compared to younger patients 7.
• The study suggests that exercise treatment, such as VHT, may be a useful approach for elderly patients with BPPV 7.
• When considering medication treatment for BPPV in elderly patients, it is essential to weigh the potential benefits against the risks of adverse effects and interactions with other medications 6.