What medications are used to treat vertigo?

Medications for Vertigo Treatment

Vestibular suppressant medications such as antihistamines (meclizine) and benzodiazepines should NOT be routinely used to treat vertigo, particularly for benign paroxysmal positional vertigo (BPPV), as they do not address the underlying cause and may interfere with the brain's natural compensation mechanisms. 1

Primary Treatment Approach: Physical Maneuvers, Not Medications

• The first-line treatment for posterior canal BPPV is canalith repositioning procedures (such as the Epley maneuver), which achieve 78.6%-93.3% improvement rates compared to only 30.8% with medication alone. 2
• Physical repositioning maneuvers directly address the underlying pathophysiology by relocating displaced otoconia, whereas medications only mask symptoms. 1
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine use of vestibular suppressants for BPPV treatment. 1

When Medications May Be Considered (Limited Scenarios)

Short-Term Symptom Relief Only

• Meclizine (antihistamine) may be used at 25-100 mg daily in divided doses for short-term management of severe vertigo symptoms, but only as a temporary measure. 3
• Prochlorperazine (5-10 mg four times daily) may be considered specifically for managing severe nausea and vomiting associated with acute vertigo episodes. 2
• Benzodiazepines (such as diazepam 10 mg) can be used for acute spontaneous vertigo to decrease vestibular damage, but only in the immediate acute phase. 4

Critical Limitations of Medication Use

• Long-term use of vestibular suppressants delays rather than enhances vestibular compensation, potentially prolonging recovery. 5, 6
• These medications are a significant independent risk factor for falls, especially in elderly patients. 5, 2
• Vestibular suppressants can decrease diagnostic sensitivity during Dix-Hallpike maneuvers, potentially interfering with proper diagnosis. 2

Medication Classes and Their Mechanisms

Antihistamines

• Meclizine works by suppressing the central emetic center and reducing vestibular system activity. 7, 3
• Common side effects include drowsiness, dry mouth, headache, fatigue, and blurred vision. 3
• Contraindicated in patients with hypersensitivity, and should be used with caution in asthma, glaucoma, or prostate enlargement. 3

Anticholinergics

• Block acetylcolina neurotransmission to reduce neural mismatch in motion-related vertigo. 7
• Should be avoided in elderly patients due to increased fall risk and cognitive side effects. 5, 7

Phenothiazines (Prochlorperazine, Promethazine)

• Work by inhibiting dopamine receptors to reduce nausea and vomiting, not the vertigo itself. 2
• Promethazine carries risks of hypotension, respiratory depression, and extrapyramidal effects. 7

Preferred Non-Pharmacological Approaches

• Vestibular rehabilitation therapy promotes central compensation and achieves long-term recovery superior to medications. 5, 2
• Patients should be reassessed within 1 month after initial treatment to document symptom resolution. 1, 2
• For treatment failures, re-evaluate for unresolved BPPV or underlying peripheral vestibular/central nervous system disorders rather than escalating medications. 1

Common Pitfalls to Avoid

• Do not continue vestibular suppressants beyond the acute phase (typically 2-3 days maximum), as this delays vestibular compensation. 5, 6
• Do not use medications as primary treatment when physical maneuvers are indicated—this represents suboptimal care with inferior outcomes. 2
• Do not prescribe meclizine or other suppressants without first confirming the diagnosis with appropriate positional testing (Dix-Hallpike or supine roll test). 1
• If a medication worsens vertigo symptoms, discontinue it immediately rather than adding additional agents. 5

Specific Clinical Scenarios

Acute Vestibular Neuritis

• Brief use of vestibular suppressants (2-3 days maximum) may be appropriate during the acute phase. 8
• Transition quickly to vestibular rehabilitation to promote compensation. 8

Ménière's Disease

• Salt restriction and diuretics are used for prevention, not acute symptom management. 8
• Vestibular suppressants may be used during acute attacks but should not be continued chronically. 8

Vestibular Migraine

• Prophylactic agents (calcium channel antagonists, tricyclic antidepressants, beta-blockers) are the mainstay, not acute vestibular suppressants. 8