What medications can be given to a patient with persistent vertigo 10 days after a brainstem infarct?

Management of Persistent Vertigo After Brainstem Infarct

For persistent vertigo 10 days after a brainstem infarct, avoid routine vestibular suppressants (antihistamines, benzodiazepines) as they interfere with central compensation, and instead consider betahistine 48 mg three times daily, which has shown benefit in improving coordination and equilibrium in post-stroke vertigo patients. 1

Medication Approach

Primary Recommendation: Betahistine

• Betahistine 48 mg three times daily (144 mg/day total) is the preferred pharmacologic option for persistent vertigo following brainstem infarction 1, 2
• In a study of 65 patients with vertigo in early rehabilitation after ischemic stroke, betahistine 8-16 mg three times daily for 14 days significantly reduced vertigo intensity and duration, improved coordination and equilibrium, and enhanced postural stability 1
• The mechanism involves increasing inner-ear blood flow and potentially activating cholinergic systems in the brain that may correct cardiovagal dysfunction seen in brainstem infarction 3, 4
• Betahistine has no sedative effect and is suitable for long-term treatment, making it appropriate for the rehabilitation phase 2

Medications to AVOID

Do not use vestibular suppressants (antihistamines like meclizine or benzodiazepines like diazepam) beyond the acute phase 5, 6

• These medications interfere with central compensation mechanisms that are critical for recovery after vestibular damage 5
• At 10 days post-stroke, you are past the acute phase where brief vestibular suppression might be justified 6
• Vestibular suppressants increase fall risk, cause sedation, and impair the brain's ability to adapt to the vestibular injury 5, 7
• Studies show no additional benefit of benzodiazepines or antihistamines over placebo for vertigo recovery 5

Symptomatic Management Only When Necessary

If severe nausea/vomiting persists despite betahistine:

• Metoclopramide 10 mg IV/IM can be used for acute antiemetic control 8
• Diphenhydramine 50 mg IM may be used for severe autonomic symptoms, but only as a rescue medication, not for routine use 5, 8
• These should be short-term interventions (days, not weeks) to avoid interfering with vestibular compensation 5, 6

Critical Considerations

Why This Differs from Peripheral Vertigo

• The guidelines recommending against vestibular suppressants primarily address BPPV and Ménière's disease, which are peripheral vestibular disorders 5
• Brainstem infarction causes central vestibular dysfunction with autonomic components, which may respond differently to pharmacotherapy 3
• Studies specifically in stroke patients show betahistine improves both clinical symptoms and objective stabilometric parameters 1

Autonomic Dysfunction Component

• Patients with brainstem infarction often have mild autonomic dysfunction contributing to vertigo, dizziness, and orthostatic symptoms 3
• This autonomic component may explain why betahistine (which has vasodilatory and cholinergic effects) shows benefit in this population 3, 1

Contraindications to Monitor

• Betahistine is contraindicated in pheochromocytoma 9, 7
• Use with caution if the patient has asthma or peptic ulcer disease 9, 7
• Common side effects include headache, nausea, and gastrointestinal symptoms 9

Reassessment Timeline

• Reassess within 1 month to document symptom resolution or persistence 5, 7
• If symptoms improve, consider titrating down betahistine after 8-12 weeks of treatment 5, 1
• If no improvement after 4-8 weeks of betahistine, consider vestibular rehabilitation therapy rather than adding vestibular suppressants 5, 6
• Persistent symptoms despite appropriate treatment warrant neuroimaging to exclude progression or new pathology 5