What medications are recommended for a patient experiencing vertigo?

Medication for Vertigo

Medications should only be used for short-term symptomatic relief of severe nausea, vomiting, or disabling vertigo—not as primary treatment—because they do not address underlying pathology, can delay recovery by interfering with vestibular compensation, and significantly increase fall risk, especially in elderly patients. 1

Primary Treatment Principle

• The underlying cause of vertigo must guide treatment, with physical maneuvers (not medications) serving as first-line therapy for the most common cause, BPPV 1, 2
• Canalith repositioning maneuvers achieve 78.6-93.3% improvement for BPPV, whereas medication alone achieves only 30.8% improvement 1
• Medications are reserved for managing severe autonomic symptoms (nausea/vomiting) or providing brief symptomatic relief during acute vestibular crises 1, 2

Medication Options by Clinical Scenario

Meclizine (First-Line Vestibular Suppressant)

• Dosing: 25-100 mg daily in divided doses, used as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 2, 3
• FDA-approved indication: Treatment of vertigo associated with diseases affecting the vestibular system in adults 3
• Use for: Short-term management of peripheral vertigo (vestibular neuritis, Ménière's attacks), but NOT as primary treatment for BPPV 1, 2
• Critical limitation: Should be used with extreme caution in elderly patients due to anticholinergic effects (cognitive impairment, urinary retention, constipation) and significantly increased fall risk 1, 4

Antiemetics for Severe Nausea/Vomiting

• Prochlorperazine: 5-10 mg orally or intravenously, maximum three doses per 24 hours, for short-term management of severe nausea/vomiting only—not as primary vertigo treatment 2, 4
• Ondansetron: Alternative with fewer CNS side effects compared to prochlorperazine 2
• Metoclopramide: Can be used for BPPV-associated nausea during repositioning maneuvers, but never as primary BPPV treatment 2

Benzodiazepines (Use with Extreme Caution)

• Diazepam: 10 mg intramuscularly once or twice daily for very short-term use in acute vestibular crises 5
• Indication: May help with psychological anxiety component of vertigo 1, 4
• Major warnings: Significant fall risk (especially in elderly), dependence potential, and interference with vestibular compensation—limit to very short-term use only 1, 4

Specific Clinical Algorithms

For BPPV (Most Common Cause)

• DO NOT use medications as primary treatment 1, 2
• Perform canalith repositioning maneuvers (Epley or Semont) as first-line therapy 1, 2
• Consider meclizine or antiemetics ONLY for:
  • Short-term management of severe nausea/vomiting during repositioning procedures 1, 2
  • Prophylaxis in patients with prior severe nausea during maneuvers 1, 2
  • Patients who refuse repositioning procedures 1, 2

For Acute Vestibular Neuritis

• Meclizine 25-100 mg daily (PRN dosing preferred) for short-term symptomatic relief 2, 4
• Add prochlorperazine if severe nausea/vomiting present 4
• Discontinue vestibular suppressants as soon as possible and transition to vestibular rehabilitation therapy 1, 4

For Ménière's Disease Attacks

• Limited course of vestibular suppressants (meclizine or benzodiazepines) during acute attacks only—NOT as continuous therapy 2, 4
• Long-term management relies on dietary salt restriction and diuretics, not vestibular suppressants 2, 6
• Note: Betahistine showed no significant benefit over placebo in reducing vertigo attack frequency in the 2020 BEMED trial 4

Critical Safety Warnings

• Fall risk: Vestibular suppressants, particularly benzodiazepines, are a significant independent risk factor for falls, especially in elderly patients 1, 4
• Delayed recovery: Long-term use impairs central nervous system compensation for peripheral vestibular damage, worsening long-term outcomes 1, 4
• Anticholinergic burden: Meclizine causes cognitive impairment, urinary retention, constipation, and increased fall risk in elderly patients 1, 4
• Drowsiness: All vestibular suppressants cause drowsiness and cognitive deficits that interfere with driving and operating machinery 4, 3

Common Pitfalls to Avoid

• Do not prescribe meclizine routinely for elderly patients with dizziness due to high fall risk and anticholinergic side effects 2
• Do not use scheduled dosing of vestibular suppressants—PRN dosing is preferred to minimize interference with vestibular compensation 2, 4
• Do not continue medications beyond acute symptom management—reassess within 1 month and transition to vestibular rehabilitation 2, 4
• Do not use medications as monotherapy for BPPV—this represents substandard care given the superior efficacy of repositioning maneuvers 1, 2

Follow-Up Requirements

• Reassess patients within 1 month after initial treatment to document symptom resolution or persistence 2, 4
• Discontinue vestibular suppressants as soon as possible 1, 4
• Transition from medication to vestibular rehabilitation therapy when appropriate to promote long-term recovery 2, 4