What are the medication options for treating vertigo?

Medication Therapy for Vertigo

Vestibular suppressant medications such as antihistamines (meclizine) and benzodiazepines should NOT be routinely used to treat vertigo, particularly BPPV, as they do not address the underlying cause and may delay recovery by interfering with natural vestibular compensation mechanisms. 1

Primary Treatment Approach: Non-Pharmacological First

The first-line treatment for the most common cause of vertigo (BPPV) is particle repositioning procedures (Epley maneuver), NOT medications. 1

• Particle repositioning maneuvers achieve 78.6%-93.3% improvement rates compared to only 30.8% with medication alone 2
• Canalith repositioning procedures should be performed for posterior canal BPPV as initial therapy 1
• Vestibular rehabilitation therapy (either self-administered or with a clinician) may be offered as adjuvant treatment, particularly for residual dizziness and balance issues after successful repositioning 1

When Medications May Be Considered (Limited Indications)

Very Short-Term Symptom Relief Only

Vestibular suppressants should only be used briefly for severely symptomatic patients who require immediate relief before definitive treatment can be provided. 1, 2

• Meclizine is FDA-approved for vertigo associated with vestibular system diseases at doses of 25-100 mg daily in divided doses 3
• However, meclizine and similar vestibular suppressants have no evidence supporting effectiveness as definitive primary treatment 1
• These medications may be considered immediately before/after repositioning procedures in severely symptomatic patients 1

Severe Nausea Management

Prochlorperazine may be used specifically for managing severe nausea and vomiting associated with vertigo, not for treating the vertigo itself. 2

• This is a phenothiazine dopamine antagonist that reduces nausea rather than addressing vertigo's root cause 2
• Should only be used as temporary symptomatic relief 2

Benzodiazepines for Specific Situations

Benzodiazepines (such as diazepam 10 mg IM) may be considered for acute spontaneous vestibular failure with severe symptoms or when anxiety is a prominent component. 4, 5

• Useful in acute vestibular neuritis during the initial severe phase 4
• May help with psychogenic vertigo associated with panic disorder or anxiety 4
• Should be limited to brief use only, as prolonged use delays vestibular compensation 4, 6

Critical Warnings About Medication Use

Why Routine Medication Use Is Harmful

Vestibular suppressant medications interfere with the brain's natural compensation mechanisms for vestibular disorders, potentially prolonging symptoms and disability. 1, 7

• Long-term use delays central vestibular compensation that is necessary for recovery 7, 6
• These medications can mask symptoms without treating the underlying pathology 7
• They may decrease diagnostic sensitivity during Dix-Hallpike maneuvers, interfering with proper diagnosis 1, 2

Significant Safety Concerns

Vestibular suppressants are a significant independent risk factor for falls, especially in elderly patients. 7, 2

• Anticholinergic medications like meclizine should be prescribed with caution in patients with asthma, glaucoma, or prostate enlargement 3
• Common adverse effects include drowsiness, cognitive deficits, and impaired ability to drive or operate machinery 2, 3
• Prochlorperazine can cause hypotension, respiratory depression, and extrapyramidal effects 8

Specific Medication Recommendations by Vertigo Type

BPPV (Most Common)

No routine medication therapy recommended. 1

• Treatment is particle repositioning maneuvers 1
• Medications only if severely symptomatic and refusing other treatment 1

Ménière's Disease

Salt restriction (1500-2300 mg daily) and diuretics are used for prevention, not acute treatment. 7, 4

• Vestibular suppressants may be used during acute attacks only 4
• Prophylactic approach is preferred over symptomatic medication 4

Vestibular Neuritis

Brief use of vestibular suppressants during the acute phase only. 4

• Benzodiazepines or antihistamines for 1-3 days maximum 4
• Early mobilization and vestibular rehabilitation should follow 4

Vestibular Migraine

Prophylactic medications (calcium channel antagonists, tricyclic antidepressants, beta-blockers) are the mainstay, not acute vestibular suppressants. 4

What to Do If Medications Worsen Vertigo

Any medication that persistently worsens vertigo symptoms should be discontinued immediately. 7

• Medications interfering with vestibular compensation may paradoxically worsen symptoms 7
• Reassess the diagnosis if symptoms don't improve with appropriate treatment 1

Follow-Up Requirements

Patients must be reassessed within 1 month after initial treatment to document resolution or persistence of symptoms. 1

• Evaluate treatment failures for unresolved BPPV or underlying peripheral vestibular/CNS disorders 1
• Educate patients about safety impact, potential recurrence, and importance of follow-up 1

Common Pitfalls to Avoid

• Do not prescribe vestibular suppressants as first-line or long-term therapy - this delays recovery and increases fall risk 1, 7
• Do not use medications as a substitute for proper diagnosis - different vertigo types require different treatments 1
• Do not continue medications beyond brief symptomatic relief - typically no more than a few days 4, 6
• Do not ignore the need for vestibular rehabilitation - medications alone are insufficient for optimal recovery 1