Medication for Inner Ear-Related Dizziness
For acute vertigo attacks from inner ear disorders, use meclizine 25 mg three times daily for 5-7 days, but only during active episodes—avoid chronic use as it delays vestibular compensation. 1, 2
Acute Vertigo Management
Vestibular suppressants should be limited to acute episodes only. The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends offering a limited course of vestibular suppressants only during acute vertigo attacks, not for chronic use. 3
First-Line Acute Medications
Meclizine (antihistamine): 25-100 mg daily in divided doses, FDA-approved for vertigo associated with vestibular system diseases. 2 The typical starting regimen is 25 mg three times daily for 5-7 days. 1
Dimenhydrinate (antihistamine): Alternative antihistamine option for acute episodes. 3
Benzodiazepines: Reserved for severe anxiety associated with acute attacks, but use with extreme caution due to dependence risk. 3, 4
Critical Caveat About Vestibular Suppressants
Do not use meclizine or other vestibular suppressants chronically or as first-line treatment for BPPV. 1 These medications can delay vestibular compensation—the brain's natural adaptation to inner ear dysfunction. 4 They are appropriate only for short-term symptom relief during severe acute episodes with nausea/vomiting. 1
Maintenance Therapy for Specific Inner Ear Conditions
For Ménière's Disease
Diuretics are the recommended maintenance therapy, not betahistine (which lacks strong efficacy evidence). 3
Diuretics (hydrochlorothiazide, chlorthalidone, acetazolamide): Modify electrolyte balance in endolymph to reduce volume and prevent attacks. 3, 5
Betahistine: The American Academy of Otolaryngology-Head and Neck Surgery cannot make a definitive recommendation due to questionable efficacy—the BEMED trial showed no significant difference versus placebo. 3 However, it remains used in some countries as a histamine analogue that increases inner ear vasodilation. 3
Dietary sodium restriction (1500-2300 mg daily) is foundational and should accompany any pharmacotherapy. 3
For Refractory Ménière's Disease
When oral medications fail:
Intratympanic steroids: 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy. 3 Risks include hearing loss and tympanic membrane perforation. 3
Intratympanic gentamicin: 73.6% complete vertigo control rate through chemical ablation of vestibular function. 6, 3 Weekly titration method shows better hearing preservation (13.1% hearing loss) versus multiple daily dosing (34.7% hearing loss). 6
For Vestibular Neuritis/Labyrinthitis
Brief vestibular suppressants only during the acute phase (first 24-48 hours). 4
Steroids may help reduce inflammation in vestibular neuritis. 7
Early vestibular rehabilitation is crucial after the acute phase to promote compensation—do not continue suppressants beyond initial days. 4
Special Population Considerations
Reduce meclizine doses in elderly patients or those with hepatic/renal impairment due to altered drug metabolism. 1 The drug is metabolized by CYP2D6, creating potential for drug interactions with CYP2D6 inhibitors. 2
Avoid meclizine in patients with:
- Asthma, glaucoma, or prostate enlargement (anticholinergic effects). 2
- Need to operate machinery (causes drowsiness). 2
- Concurrent CNS depressants including alcohol (increased sedation). 2
What NOT to Use
The American Academy of Otolaryngology-Head and Neck Surgery recommends against positive pressure therapy (Meniett device) based on systematic reviews showing no significant difference versus placebo. 3
Vestibular suppressants are not appropriate for:
- BPPV (use canalith repositioning maneuvers instead). 1
- Chronic maintenance therapy (delays compensation). 4
- Bilateral vestibular loss (no benefit, worsens function). 4
Monitoring Requirements
Document vertigo frequency, hearing changes, and quality of life impact after initiating treatment. 3 Obtain audiograms when assessing inner ear disorders to track hearing preservation. 3 Reassess patients within 1 month after initial treatment to confirm symptom resolution. 1