What medications are recommended for a patient experiencing vertigo?

Medications for Vertigo

For acute peripheral vertigo, use meclizine 25-100 mg daily in divided doses as needed for short-term symptom relief only, not as definitive treatment, and transition to vestibular rehabilitation within 1 month. 1, 2

Medication Selection by Vertigo Type

Non-BPPV Peripheral Vertigo (Vestibular Neuritis, Ménière's Disease)

First-line symptomatic treatment:

• Meclizine 25-100 mg daily in divided doses is the most commonly used antihistamine for peripheral vertigo 1, 2, 3
• Use as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 1
• FDA-approved for vertigo associated with vestibular system diseases 3

For severe nausea/vomiting:

• Prochlorperazine 5-10 mg orally or IV, maximum three doses per 24 hours 1
• Use only for short-term management of severe autonomic symptoms, not as primary vertigo treatment 1, 4

For anxiety component:

• Benzodiazepines (e.g., diazepam 5-10 mg) for short-term use to manage psychological anxiety secondary to vertigo 1, 2
• Equally effective as meclizine for symptom relief 5

BPPV (Benign Paroxysmal Positional Vertigo)

Do NOT use medications as primary treatment for BPPV 2, 4

• Canalith repositioning maneuvers (Epley, Semont) are first-line with 78.6-93.3% success rates vs. 30.8% with medication alone 2, 4
• Medications explicitly not recommended by the American Academy of Otolaryngology-Head and Neck Surgery 2

Very limited medication role in BPPV:

• Meclizine may be considered only for severe nausea during repositioning maneuvers or for patients refusing other treatment 2
• Antiemetics (prochlorperazine, metoclopramide, ondansetron) for severe nausea only, never as primary treatment 2, 4

Ménière's Disease Attacks

• Limited course of vestibular suppressants (meclizine or benzodiazepines) during acute attacks only, not continuous therapy 1, 2
• Long-term management relies on dietary salt restriction and diuretics, not vestibular suppressants 1
• Betahistine showed no significant benefit over placebo in the 2020 BEMED trial 1

Critical Safety Warnings

Significant adverse effects of vestibular suppressants:

• Drowsiness and cognitive deficits interfering with driving 1, 2, 3
• Independent risk factor for falls, especially in elderly patients 1, 2
• Anticholinergic effects: dry mouth, blurred vision, urinary retention 2
• Long-term use interferes with central vestibular compensation 1

Contraindications and cautions:

• Use with caution in asthma, glaucoma, or prostate enlargement due to anticholinergic action 3
• Avoid alcohol and other CNS depressants 3
• Monitor for drug interactions with CYP2D6 inhibitors 3

Treatment Algorithm

1. Identify vertigo type (BPPV vs. non-BPPV peripheral vs. central) 2

2. For BPPV: Perform canalith repositioning maneuvers, avoid routine medications 2, 4

3. For non-BPPV peripheral vertigo:

   • Start meclizine 25-100 mg daily PRN for severe symptoms 1, 2, 3
   • Add prochlorperazine 5-10 mg for severe nausea/vomiting 1
   • Consider benzodiazepine for significant anxiety 1, 2

4. Limit vestibular suppressants to short-term use only (days, not weeks) 1, 2

5. Reassess within 1 month to document symptom resolution and transition to vestibular rehabilitation 1, 2

Essential Lifestyle Modifications

Implement alongside medications:

• Limit salt/sodium intake (especially for Ménière's disease) 1, 2
• Avoid excessive caffeine, alcohol, and nicotine 1, 2
• Maintain adequate hydration, regular exercise, and sufficient sleep 1, 2
• Manage stress appropriately 1, 2

Common Pitfalls to Avoid

• Never use vestibular suppressants as definitive or long-term treatment - they delay compensation 1, 2
• Never prescribe meclizine routinely for elderly patients with dizziness due to fall risk and anticholinergic burden 2
• Never use medications as primary treatment for BPPV - repositioning maneuvers are vastly superior 2, 4
• Avoid scheduled dosing of meclizine - use PRN to minimize interference with compensation 1