What medications are used to treat vertigo?

Medications for Vertigo

Medications should NOT be used as primary treatment for most causes of vertigo, particularly BPPV, but can be used short-term for severe symptom relief in select cases. 1, 2

When Medications Are NOT Recommended

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routinely treating BPPV (the most common cause of vertigo) with vestibular suppressant medications such as antihistamines or benzodiazepines. 1, 3

• BPPV requires canalith repositioning maneuvers (Epley or Semont), which have 78.6-93.3% success rates compared to only 30.8% improvement with medication alone 3
• Vestibular suppressants do not address the underlying mechanical cause of BPPV and may delay recovery by interfering with central vestibular compensation 2, 4, 3

Short-Term Medication Options for Severe Symptoms

When medications are indicated for acute symptom management in non-BPPV peripheral vertigo:

Meclizine (First-Line Vestibular Suppressant)

• Dosage: 25-100 mg daily in divided doses, used primarily as-needed (PRN) rather than scheduled 2, 3, 5
• Mechanism: Antihistamine that suppresses the central emetic center 2
• Use for: Short-term management of severe vertigo symptoms in peripheral vestibular disorders (NOT BPPV) 2, 3
• Critical limitation: Should be used PRN to avoid interfering with vestibular compensation 2, 3

Benzodiazepines (Alternative for Severe Cases)

• Use for: Short-term management of severe vertigo with significant anxiety component 2, 3
• Recommended by: American Academy of Otolaryngology-Head and Neck Surgery 2

Prochlorperazine (For Nausea/Vomiting)

• Dosage: 5-10 mg orally or IV, maximum three doses per 24 hours 2
• Use for: Short-term management of severe nausea/vomiting associated with vertigo, NOT as primary vertigo treatment 2, 3
• Caution: Use carefully in patients with CNS depression or those using adrenergic blockers 2

Critical Warnings About Vestibular Suppressants

Significant Risks:

• Fall risk: Vestibular suppressants are an independent risk factor for falls, especially in elderly patients 2, 4, 3
• Anticholinergic effects: Drowsiness, cognitive deficits, dry mouth, blurred vision, urinary retention 4, 3, 5
• Interference with compensation: Long-term use prevents the brain's natural adaptation to vestibular dysfunction 2, 4
• Driving impairment: Can cause significant drowsiness affecting ability to operate machinery 3, 5

Duration Limits:

• Vestibular suppressants should only be used for days, not weeks 2, 3
• Transition from medication to vestibular rehabilitation as soon as tolerable 2, 3

Condition-Specific Medication Use

Ménière's Disease:

• Offer limited course of vestibular suppressants ONLY during acute attacks, not as continuous therapy 2, 3
• Primary management: dietary sodium restriction (1500-2300 mg daily) and diuretics 3, 6

Vestibular Neuritis:

• Short-term vestibular suppressants for initial stabilization 6, 7
• Followed by vestibular rehabilitation exercises 6, 7

BPPV:

• NO routine medication use 1, 3
• Meclizine may only be considered for: severe nausea prophylaxis before repositioning maneuvers, patients refusing other treatments, or short-term management of severe autonomic symptoms 3

Proper Management Algorithm

1. Diagnose the type of vertigo (BPPV vs. other peripheral vs. central causes) 1
2. For BPPV: Perform canalith repositioning procedure; avoid medications 1, 3
3. For non-BPPV peripheral vertigo with severe symptoms: Consider short-term PRN meclizine 25-100 mg daily 2, 3
4. For severe nausea/vomiting: Add prochlorperazine 5-10 mg as needed 2, 3
5. For significant anxiety component: Consider short-term benzodiazepine 2, 3
6. Reassess within 1 month to document symptom resolution and transition to vestibular rehabilitation 1, 2, 3

Essential Non-Pharmacological Management

Vestibular rehabilitation therapy is the cornerstone of long-term vertigo management and should be initiated early. 2, 3, 7

Lifestyle Modifications:

• Limit sodium intake to 1500-2300 mg daily (especially for Ménière's disease) 2, 3
• Avoid excessive caffeine, alcohol, and nicotine 2, 3
• Maintain adequate hydration, regular exercise, and sufficient sleep 2, 3
• Implement stress management techniques 2, 3

Common Pitfalls to Avoid

• Never prescribe meclizine as primary treatment for BPPV - it masks symptoms without addressing the cause 3
• Avoid scheduled dosing of vestibular suppressants - use PRN only to prevent interference with compensation 2, 3
• Don't continue medications beyond acute phase - prolonged use delays recovery 2, 4
• Be especially cautious in elderly patients - high fall risk and anticholinergic burden 4, 3
• If medication worsens symptoms, discontinue immediately and reassess diagnosis 4