What are the oral medication options for Benign Paroxysmal Positional Vertigo (BPPV)?

From the Guidelines

For benign paroxysmal positional vertigo (BPPV), oral medications are not recommended as a primary treatment, and canalith repositioning procedures, such as the Epley maneuver, should be the first line of treatment. The use of vestibular suppressant medications has been shown to have no significant benefit in treating BPPV, and may even cause harm due to potential side effects such as drowsiness, cognitive deficits, and increased risk of falls 1.

When medications are needed, they should be used for short-term management of autonomic symptoms, such as nausea or vomiting, in severely symptomatic patients. In such cases, antiemetics like promethazine or ondansetron may be considered for prophylaxis or treatment of nausea and vomiting. However, benzodiazepines like diazepam should be used with caution and only for a short duration (typically 2-3 days) due to their potential for sedation and addiction.

Some studies have suggested that betahistine may be effective in reducing symptoms in select patients, such as those over 50 years old with hypertension, symptom onset less than 1 month, and brief attacks less than 1 minute, when used concurrently with canalith repositioning maneuvers 1. However, the evidence for this is limited, and more research is needed to confirm its effectiveness.

In general, the treatment of BPPV should focus on canalith repositioning procedures, and medications should only be used as an adjunct therapy for short-term management of symptoms. It is essential to weigh the potential benefits and risks of medication use in each patient and to consider the potential for harm, particularly in elderly patients who may be at increased risk of falls and other adverse effects.

Key points to consider when treating BPPV include:

• Canalith repositioning procedures, such as the Epley maneuver, should be the first line of treatment
• Vestibular suppressant medications are not recommended as a primary treatment
• Medications may be used for short-term management of autonomic symptoms, such as nausea or vomiting
• Benzodiazepines should be used with caution and only for a short duration due to their potential for sedation and addiction
• Betahistine may be effective in reducing symptoms in select patients, but more research is needed to confirm its effectiveness.

From the FDA Drug Label

Meclizine hydrochloride tablets are indicated for the treatment of vertigo associated with diseases affecting the vestibular system in adults. The recommended dosage is 25 mg to 100 mg daily administered orally, in divided doses, depending upon clinical response.

Benign Paroxysmal Vertigo Oral Med Options:

• Meclizine is an option for the treatment of vertigo associated with diseases affecting the vestibular system in adults.
• The recommended dosage of meclizine is 25 mg to 100 mg daily administered orally, in divided doses, depending upon clinical response 2.

From the Research

Benign Paroxysmal Vertigo Oral Medication Options

• The most effective treatment method for benign paroxysmal positional vertigo (BPPV) is the canalith repositioning (CRP) maneuver or the Epley maneuver 3, 4, 5.
• Addition of betahistine or dimenhydrinate pharmacotherapy to repositioning maneuver did not show superiority to treatment with repositioning maneuvers alone 3.
• Vestibular suppressants such as meclizine, antihistamines, phenothiazines, anticholinergics, and/or benzodiazepines may have no effect on symptom resolution at the point of longest follow-up 5.
• Betahistine add-on therapy in posterior benign paroxysmal positional vertigo resulted in improvements in both visual analog scale score and dizziness handicap inventory 6.
• Common oral medications used for BPPV include:
  • Betahistine: 24 mg twice daily for 10 days 3, or as an add-on therapy to the Epley maneuver 6.
  • Dimenhydrinate: 50 mg once daily for five days 3.
  • Meclizine: not recommended by current guidelines 4.

Efficacy of Oral Medications

• The efficacy of oral medications for BPPV is uncertain, with some studies showing no effect on symptom resolution 5.
• The Epley maneuver is effective for treatment of benign paroxysmal positional vertigo, with a success rate of 95% 6.
• Betahistine add-on treatment in posterior benign paroxysmal positional vertigo resulted in significant improvements in visual analog scale score and dizziness handicap inventory 6.

Safety and Side Effects

• Vestibular suppressants have an uncertain effect on adverse events 5.
• Betahistine and dimenhydrinate are generally well-tolerated, but may cause side effects such as drowsiness, dry mouth, and nausea 3, 6.