What are vestibular suppressants for a 40-year-old woman with persistent dizziness and vertigo?

What Are Vestibular Suppressants

Vestibular suppressants are medications that reduce the sensation of vertigo and associated nausea by dampening the activity of the vestibular system, but they should only be used for short-term symptomatic relief of severe symptoms—not as definitive treatment—because they do not address underlying pathology and can impair long-term recovery. 1

Mechanism and Drug Classes

Vestibular suppressants work by reducing the neural activity in the vestibular system and central emetic centers. 2 The main classes include:

• Antihistamines (e.g., meclizine): Suppress the central emetic center and reduce vestibular nerve activity 3
• Anticholinergics: Block muscarinic receptors in the vestibular nuclei 2, 4
• Benzodiazepines (e.g., diazepam): Enhance GABA-mediated inhibition, reducing vestibular neuron excitability and addressing the anxiety component of vertigo 1, 2
• Antiemetics (e.g., prochlorperazine, ondansetron): Primarily target nausea and vomiting through dopamine or serotonin receptor blockade 1, 5

Clinical Indications and Appropriate Use

The American Academy of Otolaryngology-Head and Neck Surgery recommends vestibular suppressants only for short-term symptomatic relief of severe nausea, vomiting, or disabling vertigo. 1

Appropriate scenarios include:

• Acute vestibular neuritis or Ménière's disease attacks: Limited course during acute episodes only, not continuous therapy 3, 5
• Severe autonomic symptoms: Short-term management of nausea/vomiting during or after repositioning maneuvers for BPPV 1, 5
• Prophylaxis: For patients with prior severe nausea during procedures 5
• Patient refusal: When patients refuse repositioning procedures 5

Specific Medication Recommendations

Meclizine (First-Line)

• The American Academy of Otolaryngology-Head and Neck Surgery suggests meclizine as first-line treatment for vertigo associated with vestibular system diseases. 1
• Dosing: 25-100 mg daily in divided doses 5
• Should be used primarily as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 3, 5
• FDA-indicated for treatment of vertigo associated with diseases affecting the vestibular system 6

Benzodiazepines

• May help with the psychological anxiety component of vertigo 1
• Should be limited to very short-term use due to dependence potential and interference with vestibular compensation 1

Antiemetics

• Prochlorperazine and ondansetron for severe nausea/vomiting 1
• Should be used as adjunctive therapy only, not primary treatment 1, 5

Critical Safety Warnings and Contraindications

Vestibular suppressants carry significant risks that often outweigh benefits, particularly with prolonged use:

• Fall risk: Vestibular suppressants, particularly benzodiazepines, are a significant independent risk factor for falls, especially in elderly patients 1, 3, 5
• Impaired compensation: Long-term use can impair central nervous system compensation for peripheral vestibular damage, delaying recovery and worsening long-term outcomes 1, 3
• Anticholinergic burden: Meclizine contributes to cognitive impairment, urinary retention, constipation, and increased fall risk in elderly patients 1, 5
• Cognitive deficits: Drowsiness and cognitive impairment can interfere with driving or operating machinery 3, 5

When NOT to Use Vestibular Suppressants

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine treatment of BPPV with vestibular suppressant medications. 5

• BPPV: Canalith repositioning maneuvers achieve 78.6-93.3% improvement versus only 30.8% with medication alone 1, 5
• Elderly patients with dizziness: Should not be routinely prescribed due to significant fall risk and anticholinergic side effects 5
• Long-term management: Not appropriate for chronic or maintenance therapy 1, 3

Clinical Algorithm for Use

1. Diagnose the specific vestibular disorder first 1
2. For BPPV: Use repositioning maneuvers as primary treatment; reserve medications only for severe nausea during procedures 1, 5
3. For acute vestibular neuritis or Ménière's attack: Meclizine and antiemetics may be used for short-term symptomatic relief 1
4. Discontinue as soon as possible: Transition to vestibular rehabilitation therapy within days to weeks 1, 3
5. Reassess within 1 month: Document resolution or persistence of symptoms and transition from medication to rehabilitation when appropriate 3, 5

Important Caveats

• Betahistine showed no significant benefit over placebo in reducing vertigo attack frequency in Ménière's disease according to the 2020 BEMED trial 3
• Patients who underwent repositioning maneuvers alone recovered faster than those who received concurrent vestibular suppressants 5
• Use PRN dosing rather than scheduled to minimize interference with central compensation mechanisms 3, 5