What are the first-line medications for treating vertigo?

First-Line Medications for Vertigo

For acute peripheral vertigo, meclizine (25-100 mg daily in divided doses) is the most commonly used first-line medication, though it should be used primarily as-needed for short-term symptom management rather than as definitive treatment. 1, 2, 3

Medication Selection by Clinical Context

For Non-BPPV Peripheral Vertigo (Vestibular Neuritis, Labyrinthitis)

• Meclizine is the primary first-line agent, FDA-approved for vertigo associated with vestibular system diseases, with dosing of 25-100 mg daily in divided doses 3
• Use meclizine as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation, which is critical for long-term recovery 1
• Benzodiazepines (e.g., diazepam) may be added for short-term management when severe symptoms are present or when significant psychological anxiety accompanies vertigo 1, 4
• A 2017 randomized controlled trial found diazepam 5 mg and meclizine 25 mg equally effective, with mean VAS improvements of 36 and 40 respectively at 60 minutes (no significant difference, p=0.60) 5

For Ménière's Disease Acute Attacks

• Limited course of vestibular suppressants (meclizine or benzodiazepines) should be offered only during acute attacks, not as continuous therapy 6, 1, 2
• Betahistine showed no significant benefit over placebo in the 2020 BEMED trial for reducing vertigo attack frequency over 9 months, despite earlier meta-analyses suggesting benefit 6
• Long-term management relies on dietary modifications (salt restriction) and diuretics rather than vestibular suppressants 6, 7

For BPPV

• Medications are NOT recommended as first-line treatment - canalith repositioning maneuvers (Epley, Semont) are the definitive treatment with 78.6-93.3% success rates compared to 30.8% with medication alone 2
• Meclizine may only be considered for severe nausea/vomiting during repositioning procedures or as prophylaxis in patients who previously experienced severe nausea during maneuvers 2

For Severe Nausea/Vomiting

• Prochlorperazine (5-10 mg orally or IV, maximum three doses per 24 hours) can be added for short-term management of severe nausea/vomiting, but is not primary treatment for vertigo itself 1, 2

Critical Safety Considerations

Significant Risks with Vestibular Suppressants

• Fall risk is substantially increased, particularly in elderly patients - vestibular suppressants are an independent risk factor for falls 1, 2
• Anticholinergic side effects include drowsiness, cognitive deficits, dry mouth, blurred vision, urinary retention, and interference with driving or operating machinery 1, 3
• Long-term use interferes with central vestibular compensation, delaying recovery from peripheral vestibular lesions 1, 8
• Meclizine should be prescribed with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 3

Special Populations

• Elderly patients: Meclizine should not be routinely prescribed due to high fall risk, anticholinergic burden, and polypharmacy concerns 2
• Benzodiazepines: All carry significant risk for drug dependence and should be limited to short-term use 4

Treatment Algorithm

1. Identify vertigo type through history (onset, duration, triggers) and physical examination (nystagmus pattern, neurological deficits) 2, 9

2. For BPPV: Perform canalith repositioning maneuvers, avoid routine medication use 2

3. For acute peripheral vertigo (non-BPPV):

   • Start meclizine 25-100 mg daily PRN for severe symptoms 1, 3
   • Add benzodiazepine if significant anxiety component present 1, 4
   • Add prochlorperazine if severe nausea/vomiting 1

4. For Ménière's disease:

   • Vestibular suppressants only during acute attacks 6, 2
   • Implement dietary modifications (salt restriction <1500-2000 mg/day) 2

5. Reassess within 1 month to document symptom resolution and transition from medication to vestibular rehabilitation therapy when appropriate 1, 2

Essential Counseling Points

• Limit vestibular suppressants to short-term use only (days, not weeks) to promote natural compensation 1, 8
• Avoid driving or operating machinery while taking these medications 1, 3
• Implement lifestyle modifications: adequate hydration, regular exercise, sufficient sleep, stress management, and avoidance of excessive caffeine, alcohol, and nicotine 1, 2
• For Ménière's disease specifically, strict sodium restriction (limiting salt intake) is essential for long-term management 2, 7