What are the pharmacological treatment options for vertigo?

Pharmacological Treatment for Vertigo

Vestibular suppressant medications should be reserved strictly for short-term management of severe symptoms (typically 1-3 days maximum) rather than as definitive treatment, with meclizine 25-100 mg daily being the first-line agent for acute peripheral vertigo, while BPPV should be treated with canalith repositioning maneuvers, not medications. 1, 2

Medication Selection by Clinical Context

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

First-Line Agent:

• Meclizine 25-100 mg daily in divided doses is the most commonly used antihistamine for peripheral vertigo, working by suppressing the central emetic center 1, 3
• Should be used primarily as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 1, 2
• FDA-approved for treatment of vertigo associated with diseases affecting the vestibular system 3

Alternative/Adjunctive Agents:

• Benzodiazepines (e.g., diazepam 5 mg) may be used for short-term management of severe vertigo symptoms and can help with psychological anxiety secondary to vertigo 1, 4
• Diazepam and meclizine show equivalent efficacy in emergency department studies, with no significant difference in symptom improvement 5
• Prochlorperazine 5-10 mg orally or IV (maximum three doses per 24 hours) for short-term management of severe nausea or vomiting, but not as primary treatment for vertigo itself 1, 2

For Ménière's Disease

• Limited course of vestibular suppressants (meclizine or benzodiazepines) only during acute attacks, not as continuous therapy 1, 2, 4
• Betahistine showed no significant benefit over placebo in reducing vertigo attack frequency over 9 months according to the 2020 BEMED trial 1
• Long-term management relies on dietary modifications (salt restriction) and diuretics rather than vestibular suppressants 1

For BPPV - Critical Exception

Medications are explicitly NOT recommended as primary treatment for BPPV 2, 4:

• Canalith repositioning maneuvers achieve 78.6-93.3% improvement versus only 30.8% improvement with medication alone 2, 4
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine treatment of BPPV with vestibular suppressants 2

Very Limited Role for Medications in BPPV:

• May consider meclizine only for prophylaxis in patients who previously manifested severe nausea during repositioning maneuvers 2
• Short-term management of severe autonomic symptoms (nausea/vomiting) in severely symptomatic patients 2
• Patients who refuse repositioning procedures 2

Critical Safety Warnings and Contraindications

Fall Risk - Especially in Elderly Patients

• Vestibular suppressants are a significant independent risk factor for falls, particularly in elderly patients 1, 4
• Meclizine should not be routinely prescribed for elderly patients experiencing dizziness due to significant fall risk and anticholinergic effects 2
• Anticholinergic side effects include drowsiness, cognitive deficits, dry mouth, blurred vision, urinary retention, and constipation 2, 4, 3

Interference with Vestibular Compensation

• Long-term use of vestibular suppressants can interfere with central compensation in peripheral vestibular conditions 1
• This impairs the central nervous system's ability to compensate for peripheral vestibular damage, delaying recovery and worsening long-term outcomes 4
• Patients who underwent repositioning maneuvers alone recovered faster than those receiving concurrent labyrinthine sedatives 2

Other Important Warnings

• Can cause significant drowsiness and cognitive deficits that interfere with driving or operating machinery 1, 2, 3
• Benzodiazepines carry dependence potential and should be limited to very short-term use 4
• Meclizine should be prescribed with care to patients with asthma, glaucoma, or prostate enlargement due to anticholinergic action 3

Treatment Algorithm

Step 1: Diagnose the Specific Vestibular Disorder

• If BPPV → Proceed directly to canalith repositioning maneuvers (Epley, Semont); avoid medications as primary treatment 2, 4
• If Ménière's disease → Use vestibular suppressants only during acute attacks; implement dietary modifications (salt restriction) and diuretics for prevention 1, 2
• If acute vestibular neuritis or labyrinthitis → Consider short-term vestibular suppressants for severe symptoms 4

Step 2: If Medications Are Indicated

• Start with meclizine 25-100 mg daily in divided doses, used PRN 1, 2, 3
• For severe nausea/vomiting, add prochlorperazine 5-10 mg (maximum three doses per 24 hours) 1
• For anxiety component, consider short-term benzodiazepine use 1

Step 3: Duration and Discontinuation

• Use vestibular suppressants for the shortest duration possible (typically 1-3 days maximum) 1, 4
• Discontinue as soon as possible to avoid interfering with vestibular compensation 4

Step 4: Transition to Definitive Treatment

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 1, 2
• Transition from medication to vestibular rehabilitation therapy when appropriate to promote long-term recovery 1, 2, 4

Lifestyle Modifications to Implement Alongside Medications

• Limiting salt/sodium intake (especially for Ménière's disease) 1, 2
• Avoiding excessive caffeine, alcohol, and nicotine 1, 2
• Maintaining adequate hydration, regular exercise, and sufficient sleep 1
• Managing stress appropriately 1, 2

Common Pitfalls to Avoid

• Do not use vestibular suppressants as primary treatment for BPPV - this delays definitive treatment and exposes patients to unnecessary medication risks 2, 4
• Do not prescribe vestibular suppressants on a scheduled basis - use PRN dosing to minimize interference with compensation 1, 2
• Do not continue vestibular suppressants beyond acute symptom management - prolonged use impairs central compensation 1, 4
• Exercise extreme caution in elderly patients - consider non-pharmacological approaches first due to fall risk and anticholinergic burden 2, 4
• Do not use betahistine for Ménière's disease prevention - evidence shows no benefit over placebo 1