What medications are used to treat dizziness associated with vestibular disorders?

Medications for Vestibular Disorder-Associated Dizziness

Vestibular suppressant medications should only be used for short-term symptomatic relief of severe nausea, vomiting, or disabling vertigo—not as primary or definitive treatment—because they do not address the underlying pathology, can significantly increase fall risk (especially in elderly patients), and may interfere with natural vestibular compensation. 1, 2

Primary Treatment Approach

The treatment strategy depends entirely on the specific vestibular disorder:

For BPPV (Most Common Vestibular Disorder)

• Do NOT use medications as primary treatment 1, 3
• Canalith repositioning maneuvers (Epley, Semont) achieve 78.6-93.3% improvement versus only 30.8% with medication alone 1
• Medications may only be considered for: 1
  • Short-term management of severe nausea/vomiting during or after repositioning maneuvers
  • Prophylaxis in patients with prior severe nausea during Dix-Hallpike testing
  • Patients who refuse repositioning procedures (though this is suboptimal)

For Non-BPPV Peripheral Vertigo (Ménière's Disease, Vestibular Neuritis)

• Use vestibular suppressants only during acute attacks, not as continuous therapy 2, 3
• Long-term management relies on addressing the underlying cause (salt restriction and diuretics for Ménière's disease, corticosteroids for vestibular neuritis) 2, 4, 5

Medication Options When Indicated

First-Line: Meclizine (Antihistamine)

• FDA-approved for vertigo associated with vestibular system diseases 6
• Dosing: 25-100 mg daily in divided doses 6
• Use PRN (as-needed) rather than scheduled to avoid interfering with vestibular compensation 2, 3
• Mechanism: Suppresses the central emetic center 2, 7
• Major contraindications/cautions: 6
  • Drowsiness—warn about driving and operating machinery
  • Anticholinergic effects (dry mouth, blurred vision, urinary retention)
  • Use with extreme caution in elderly due to fall risk and cognitive impairment
  • Avoid in patients with asthma, glaucoma, or prostatic hypertrophy

Alternative: Benzodiazepines (e.g., Diazepam)

• May help with psychological anxiety component of vertigo 1, 2
• Diazepam 5 mg showed equivalent efficacy to meclizine 25 mg in one ED trial 8
• Significant fall risk, especially in elderly patients—benzodiazepines are an independent risk factor for falls 1, 2
• Should be limited to very short-term use due to dependence potential and interference with vestibular compensation 2, 9

For Severe Nausea/Vomiting: Antiemetics

• Prochlorperazine: 5-10 mg orally or IV, maximum 3 doses per 24 hours 2
• Promethazine: 12.5-25 mg (phenothiazine with antihistamine properties) 7
• Ondansetron: 8 mg every 4-6 hours (for refractory nausea; requires baseline ECG due to QTc prolongation risk) 7
• These are adjunctive only—never use as primary vertigo treatment 2, 3

Betahistine (Not FDA-Approved in US)

• May benefit specific subgroups: patients >50 years with hypertension, symptom onset <1 month, brief attacks <1 minute, when combined with repositioning maneuvers 1
• High-dose betahistine (≥48 mg three times daily) may reduce Ménière's attack frequency by increasing inner ear blood flow 5
• However, the 2020 BEMED trial showed no significant benefit over placebo for Ménière's disease 2

Critical Safety Warnings

Fall Risk (Highest Priority for Morbidity/Mortality)

• Vestibular suppressants, particularly benzodiazepines, are a significant independent risk factor for falls 1, 2
• Risk increases with polypharmacy and in elderly patients 1
• Counsel patients about drowsiness, cognitive deficits, and impaired driving/machinery operation 1, 6

Interference with Vestibular Compensation

• Long-term use of vestibular suppressants impairs central nervous system compensation for peripheral vestibular damage 2, 7, 9
• This delays recovery and worsens long-term outcomes 2

Anticholinergic Burden in Elderly

• Meclizine contributes to anticholinergic burden causing cognitive impairment, urinary retention, constipation, and increased fall risk 1, 2, 3
• Consider avoiding meclizine entirely in elderly patients with dizziness 3

Clinical Algorithm

1. Diagnose the specific vestibular disorder (BPPV vs. Ménière's vs. vestibular neuritis vs. other)
2. For BPPV: Perform repositioning maneuvers; reserve medications only for severe nausea during procedures 1, 3
3. For acute vestibular neuritis or Ménière's attack:
   • Meclizine 25-50 mg PRN for 1-3 days maximum 2, 3
   • Add antiemetic (prochlorperazine or ondansetron) if severe nausea/vomiting 2, 7
   • Transition to vestibular rehabilitation therapy as soon as tolerated 2, 3
4. Reassess within 1 month to document symptom resolution or persistence 1, 2, 3
5. Discontinue vestibular suppressants as soon as possible and transition to vestibular rehabilitation for persistent symptoms 2, 3

Common Pitfalls to Avoid

• Never prescribe meclizine or other vestibular suppressants on a standing/scheduled basis—this delays compensation 2, 3
• Never use medications as sole treatment for BPPV—this has poor outcomes compared to repositioning 1, 3
• Avoid chronic benzodiazepine use—dependence and fall risk outweigh benefits 1, 2
• Do not overlook non-pharmacologic interventions: vestibular rehabilitation therapy is superior to medications for long-term recovery 2, 3, 9