What is the optimal pharmacotherapy for acute dizziness in an octogenarian patient in the Emergency Department?

From the Guidelines

The optimal pharmacotherapy for acute dizziness in an octogenarian patient in the Emergency Department is not recommended, except for short-term management of autonomic symptoms such as nausea or vomiting.

Key Considerations

• Vestibular suppressant medications, including benzodiazepines and antihistamines, are not effective as a definitive treatment for benign paroxysmal positional vertigo (BPPV) or as a substitute for repositioning maneuvers 1.
• These medications may produce drowsiness, cognitive deficits, and interference with driving or operating machinery, and are a significant independent risk factor for falls, particularly in the elderly 1.
• The use of vestibular suppressants may also expose patients to additional risk due to polypharmacy 1.

Pharmacotherapy Options

• Meclizine and diphenhydramine are common examples of antihistamines used to treat symptoms of vertigo and associated motion sickness, but their use is not recommended for routine treatment of BPPV 1.
• Benzodiazepines, such as diazepam and clonazepam, may be used for short-term management of autonomic symptoms, but their use should be cautious due to the risk of falls and cognitive deficits 1.
• Ondansetron may be considered for prophylaxis in patients who have previously manifested severe nausea and/or vomiting with the Dix-Hallpike maneuvers and in whom a canal repositioning procedure is planned 1.

Clinical Decision Making

• The clinical detection of associated neurologic symptoms is important in triaging patients with dizziness or vertigo, and various bedside tests have been developed and validated to assist in triaging patients to one of several defined “dizziness syndromes” 1.
• Imaging studies, such as head CT or MRI, may be considered in patients with associated neurologic findings or in those with a high risk of stroke or other life-threatening conditions 1.

From the Research

Optimal Pharmacotherapy for Acute Dizziness

The optimal pharmacotherapy for acute dizziness in an octogenarian patient in the Emergency Department is not clearly established. However, several studies provide insights into the effectiveness of various medications:

• A study from 2004 2 suggests that pharmacotherapy for acute spontaneous vertigo may include Levo-sulpiride, methoclopramide, triethilperazine, diazepam, sulfate magnesium, or piracetam to reduce neurovegetative symptoms and decrease vestibular damage.
• A 2017 study 3 found that diazepam and meclizine are equally effective in the treatment of vertigo, with no significant difference in mean change in vertigo visual analog scale (VAS) scores at 60 minutes.
• A systematic review and meta-analysis from 2022 4 suggests that single-dose antihistamines may provide greater vertigo relief at 2 hours than single-dose benzodiazepines, but daily antihistamine use may not benefit patients with acute vertigo.
• Another systematic review and meta-analysis from 2023 5 found that vestibular suppressants, including antihistamines, phenothiazines, anticholinergics, and benzodiazepines, may have no effect on symptom resolution at the point of longest follow-up in patients with benign paroxysmal positional vertigo (BPPV).

Considerations for Octogenarian Patients

When considering pharmacotherapy for acute dizziness in octogenarian patients, it is essential to take into account the potential risks and benefits of each medication, as well as the patient's underlying medical conditions and medications:

• A 2006 study 6 highlights the importance of appropriate diagnosis and treatment of dizziness in older patients, as it can significantly improve quality of life.
• The choice of medication should be individualized, considering factors such as the patient's medical history, current medications, and potential interactions.

Treatment Approaches

Treatment approaches for acute dizziness in octogenarian patients may involve:

• Canalith repositioning maneuvers (CRMs) as the primary treatment for BPPV, as suggested by the 2023 systematic review and meta-analysis 5.
• Pharmacotherapy with antihistamines, benzodiazepines, or other medications, as suggested by the studies mentioned above 2, 3, 4.
• A combination of physical therapy, vestibular electrical stimulation, and pharmacotherapy, as suggested by the 2004 study 2.