Betahistine Is Not Recommended for BPPV Treatment
Betahistine is not recommended for routine treatment of Benign Paroxysmal Positional Vertigo (BPPV) and should not be used as a long-term therapy. 1, 2
First-Line Treatment for BPPV
- Canalith repositioning procedures (CRPs) are the first-line treatment for BPPV with high success rates (around 80%) with only 1-3 treatments 1
- CRPs are significantly more effective (78.6%-93.3% improvement) than medication alone (30.8% improvement) 3
- CRPs directly address the underlying cause of BPPV by guiding displaced otoconia back to their original location 1
Limited Role of Betahistine in BPPV
- Betahistine is not recommended as primary treatment for BPPV according to clinical practice guidelines 1, 2
- Betahistine may only be considered in very specific circumstances:
- In patients over 50 years old with hypertension, with symptom onset <1 month, and with brief attacks <1 minute when used concurrently with canal repositioning maneuvers 1
- For treating residual dizziness after successful treatment of otolithiasis 4
- To reduce the severity of vertigo during repositioning maneuvers 4
Duration of Betahistine Use (If Prescribed)
- If betahistine is used as an adjunct therapy, it should be limited to short-term use only 1, 2
- Vestibular suppressant medications should only be used for short-term management of autonomic symptoms, such as nausea or vomiting, in severely symptomatic patients 1, 3
- Long-term use of vestibular suppressants can interfere with central compensation in peripheral vestibular conditions, potentially prolonging symptoms 2, 5
Potential Harms of Betahistine
- All vestibular suppressants may cause drowsiness, cognitive deficits, and interference with driving or operating machinery 1
- These medications significantly increase fall risk, especially in elderly patients 1, 2
- The risk of falls increases in patients taking multiple medications 1
Follow-Up and Monitoring
- Patients should be reassessed within 1 month after initial treatment to document resolution or persistence of symptoms 1
- If symptoms persist after initial treatment, patients should be reevaluated for persistent BPPV or underlying peripheral vestibular or CNS disorders 1
- Repeat CRPs can be performed if the Dix-Hallpike maneuver remains positive, with success rates reaching 90-98% with additional repositioning maneuvers 1
Research Evidence on Betahistine for BPPV
- Some studies suggest that betahistine combined with Epley maneuver may result in less relapse and recurrence compared to Epley maneuver alone 6
- However, other research found no statistically significant differences between repositioning maneuver alone and repositioning maneuver plus betahistine 7
- The most recent evidence indicates that betahistine may help alleviate BPPV through inducing production of multiple CTRP family members and activating specific pathways 8
Conclusion
For BPPV treatment, canalith repositioning procedures remain the gold standard. If betahistine is used at all, it should be limited to short-term adjunctive therapy in specific patient populations, with reassessment within one month to evaluate response and discontinue as soon as possible.