What are the medication options for managing vertigo?

Medication Options for Vertigo

Medications should be used only for short-term management of severe vertigo symptoms rather than as definitive treatment, with meclizine (25-100 mg daily) being the first-line vestibular suppressant for acute peripheral vertigo, benzodiazepines for severe symptoms with anxiety, and prochlorperazine reserved specifically for managing severe nausea/vomiting—not the vertigo itself. 1, 2

Primary Medication Options

Meclizine (First-Line Vestibular Suppressant)

• Dosing: 25-100 mg daily in divided doses, used primarily as-needed (PRN) rather than scheduled 1, 2, 3
• Mechanism: Antihistamine that suppresses the central emetic center 1
• Key advantage: Most commonly used with potentially fewer anticholinergic effects compared to dimenhydrinate 1
• Critical limitation: Should NOT be used as primary treatment for BPPV, where canalith repositioning maneuvers achieve 78.6%-93.3% improvement versus only 30.8% with medication alone 2, 4

Benzodiazepines (For Severe Symptoms)

• Indication: Short-term management of severe vertigo symptoms, particularly when psychological anxiety is present 1, 2
• Evidence: Diazepam 5 mg showed equivalent efficacy to meclizine 25 mg in emergency department patients with acute peripheral vertigo 5
• Specific role: May help with anxiety component secondary to vertigo 1

Prochlorperazine (For Nausea/Vomiting Only)

• Dosing: 5-10 mg orally or intravenously, maximum three doses per 24 hours 1
• Critical distinction: Used for short-term management of severe nausea/vomiting associated with vertigo, NOT as primary treatment for the vertigo itself 1, 2, 4
• Mechanism: Phenothiazine that inhibits dopamine receptors, reducing nausea rather than treating underlying vertigo 4

Condition-Specific Approaches

Ménière's Disease

• Acute attacks: Limited course of vestibular suppressants (meclizine or benzodiazepines) during attacks only, not continuous therapy 1, 2
• Long-term management: Salt restriction and diuretics are the mainstay, not vestibular suppressants 1
• Important negative finding: Betahistine showed no significant benefit over placebo in the 2020 BEMED trial for reducing vertigo attack frequency over 9 months 1

BPPV (Benign Paroxysmal Positional Vertigo)

• Primary treatment: Canalith repositioning maneuvers (Epley, Semont), NOT medications 2, 4
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends AGAINST routine treatment of BPPV with vestibular suppressants 2, 4
• Very limited medication role: Only consider meclizine for severe nausea during repositioning maneuvers or as prophylaxis in patients who previously experienced severe nausea during the procedure 2, 4

Vestibular Neuritis

• Approach: Brief use of vestibular suppressants only during acute phase 6
• Rationale: Prolonged use interferes with central vestibular compensation 1

Critical Safety Warnings

Fall Risk (Especially Elderly)

• Vestibular suppressants are a significant independent risk factor for falls, particularly in elderly patients 1, 2
• The American Academy of Otolaryngology-Head and Neck Surgery recommends against routine meclizine use in elderly patients with dizziness 2
• Additional elderly concerns: Anticholinergic burden causing cognitive deficits, dry mouth, blurred vision, urinary retention 2, 3

Interference with Compensation

• Long-term use of vestibular suppressants interferes with central compensation in peripheral vestibular conditions 1
• This is why PRN dosing is preferred over scheduled dosing 1
• Patients who received repositioning maneuvers alone recovered faster than those receiving concurrent labyrinthine sedatives 2

Other Side Effects

• Drowsiness and cognitive deficits interfering with driving or operating machinery 1, 2, 3
• May decrease diagnostic sensitivity during Dix-Hallpike maneuvers 4
• Caution with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 3

Essential Follow-Up Protocol

• Reassess within 1 month after initial treatment to document resolution or persistence of symptoms 1, 2
• Transition from medication to vestibular rehabilitation when appropriate to promote long-term recovery 1, 2
• Discontinue vestibular suppressants as soon as possible 2

Adjunctive Lifestyle Modifications

• Limit salt/sodium intake (especially for Ménière's disease) 1, 2
• Avoid excessive caffeine, alcohol, and nicotine 1, 2
• Maintain adequate hydration, regular exercise, and sufficient sleep 1
• Manage stress appropriately 1, 2

Common Pitfalls to Avoid

1. Using medications as primary treatment for BPPV instead of repositioning maneuvers 2, 4
2. Prescribing vestibular suppressants on a scheduled basis rather than PRN, which delays compensation 1
3. Continuing medications beyond the acute phase, increasing fall risk and delaying recovery 1, 2
4. Using prochlorperazine to treat vertigo itself rather than just the associated nausea/vomiting 1, 4
5. Failing to reassess within 1 month and transition to vestibular rehabilitation 1, 2