What is the role of betahistine in treating dizziness (lightheadedness)?

From the Guidelines

Betahistine should not be used as a first-line treatment for vague complaints of dizziness due to its limited effectiveness and lack of clear benefits for non-specific dizziness, as evidenced by the recent BEMED trial 1. The role of betahistine in treating dizziness is primarily established for Meniere's disease, where it may help reduce vertigo episodes, but its effectiveness for general dizziness is not well-supported by high-quality evidence.

Key Points to Consider

• The BEMED trial, a well-designed study, found no significant difference in mean vertigo attack rate between betahistine and placebo groups over a 9-month treatment period 1.
• Betahistine is generally well-tolerated, but side effects can include headache, balance disorder, nausea, and gastrointestinal symptoms 1.
• The medication should be used with caution in patients with asthma, history of peptic ulcer disease, and avoided in those with pheochromocytoma 1.

Clinical Approach

When evaluating patients with vague complaints of dizziness, it is crucial to identify specific causes through proper assessment, as treatment should target the underlying condition rather than symptoms alone.

• Vestibular rehabilitation therapy, addressing cardiovascular issues, or managing medication side effects often provide better outcomes for non-specific dizziness.
• If betahistine is considered, the typical dosage is 8-16 mg three times daily, with treatment duration often extending 3-6 months to evaluate effectiveness, although there are no clear data on the optimal duration of treatment 1.

From the Research

Role of Betahistine in Dizziness

• Betahistine is a weak agonist for histamine H1 receptors and strong antagonist for histamine H3 receptors, demonstrating maximum benefit in different types of peripheral vertigo, especially in Meniere's disease 2.
• The best results in decreasing intensity of vertigo, frequency of attacks, and stimulation of vestibular compensation were obtained with a daily dose of 48 mg during 3 months 2.
• Betahistine is used to treat residual dizziness after successful treatment of otolithiasis and to reduce the severity of vertigo during repositioning maneuvers in benign paroxysmal positional vertigo 2.
• In vestibular neuritis, betahistine stimulates central compensation during vestibular rehabilitation 2.

Efficacy and Safety of Betahistine

• A multicentre, double-blind, randomized clinical study found that modified-release betahistine (48 mg once daily) is non-inferior to traditional betaserc (24 mg twice daily) in patients with Meniere's disease or vestibular vertigo, with a comparable safety profile 3.
• The study also found that betahistine MR (48 mg once daily) reduces the frequency, intensity, and duration of vertigo attacks, and improves the Dizziness Handicap Inventory (DHI) total score 3.
• Another study found that betahistine is more effective than cinnarizine in reducing symptoms of Meniere's disease, particularly in patients with a classic triad of symptoms 4.

Combination Therapy with Betahistine

• A study found that combining betahistine with the MAO-B inhibitor selegiline can achieve the same clinical effect with a significantly lower dosage of betahistine, potentially reducing the first-pass effect of betahistine 5.
• The combination therapy was found to be effective in reducing the frequency of acute attacks of vertigo in patients with Meniere's disease, with some patients reporting transient side effects such as fullness of the head 5.