What antinausea medication can be used to treat vertigo?

Antinausea Medications for Vertigo

Meclizine is the first-line antinausea medication for vertigo, used at 25-100 mg daily in divided doses, but should be prescribed only as-needed (PRN) for short-term management of acute symptoms rather than on a scheduled basis. 1, 2, 3

Primary Medication Options

Meclizine (First-Line)

• FDA-approved specifically for vertigo associated with vestibular system diseases 3
• Dose: 25-100 mg daily in divided doses 2
• Critical prescribing principle: Use PRN rather than scheduled dosing to avoid interfering with the brain's natural vestibular compensation mechanisms 1
• Works by suppressing the central emetic center 4
• Should be limited to short-term management of severe symptoms only 1

Dimenhydrinate (Alternative Antihistamine)

• FDA-approved for prevention and treatment of nausea, vomiting, or vertigo of motion sickness 5
• May have more pronounced anticholinergic side effects compared to meclizine 4
• Similar mechanism of action as meclizine 6

Prochlorperazine (For Severe Nausea/Vomiting)

• Use specifically for short-term management of severe nausea or vomiting associated with vertigo, NOT as primary treatment for vertigo itself 4, 2
• Dose: 5-10 mg orally or intravenously, maximum three doses per 24 hours 4
• Caution: Risk of extrapyramidal symptoms, especially in patients with psychiatric history 4
• Contraindicated in patients with CNS depression, concurrent use of adrenergic blockers, or severe hypotension 4

Benzodiazepines (For Severe Symptoms with Anxiety)

• May be used for short-term management of severe vertigo symptoms and can help with psychological anxiety secondary to vertigo 4
• Diazepam 5 mg orally showed equal efficacy to meclizine 25 mg in emergency department studies 7
• Particularly useful when anxiety component is prominent 4

Critical Safety Warnings and Contraindications

Fall Risk

• Vestibular suppressants are an independent risk factor for falls, especially in elderly patients 1, 2
• Should not be routinely prescribed for elderly patients experiencing dizziness 2

Anticholinergic Side Effects

• Drowsiness, cognitive deficits, dry mouth, blurred vision, and urinary retention 1, 2
• These effects are particularly problematic in elderly patients 2
• Can interfere with driving or operating machinery 2

Interference with Vestibular Compensation

• Long-term use interferes with central vestibular compensation and can prolong recovery 1, 4
• This is why PRN dosing is strongly preferred over scheduled dosing 1

Specific Precautions

• Use with caution in patients with asthma and history of peptic ulcer disease 8, 1
• Avoid in patients with pheochromocytoma (for betahistine) 8

Treatment Algorithm by Vertigo Type

BPPV (Benign Paroxysmal Positional Vertigo)

• Meclizine is NOT recommended as primary treatment for BPPV 1, 2
• Canalith repositioning maneuvers (Epley maneuver) have 78.6-93.3% success rates compared to only 30.8% with medication alone 1, 2
• Meclizine may only be considered for: 1, 2
  • Severe nausea/vomiting during repositioning procedures
  • Patients who refuse other treatments
  • Prophylaxis for patients who previously had severe nausea during maneuvers

Ménière's Disease

• Use vestibular suppressants (meclizine or benzodiazepines) only during acute attacks, not continuously 1, 4, 2
• Long-term management relies on dietary salt restriction and diuretics rather than vestibular suppressants 1, 2
• Note: Betahistine showed no significant benefit over placebo in reducing vertigo attack frequency over 9 months in the well-designed BEMED trial 8, 4

Vestibular Neuritis and Other Peripheral Vertigo

• Vestibular suppressants appropriate for short-term symptomatic relief 4, 6
• Transition to vestibular rehabilitation as soon as acute symptoms subside 4, 2

Clinical Management Protocol

Initial Prescribing

• Prescribe PRN dosing rather than scheduled to minimize interference with vestibular compensation 1
• Limit to short-term management of severe symptoms only 1, 2
• Consider adding prochlorperazine for severe nausea/vomiting 4
• Consider short-term benzodiazepine for prominent anxiety component 4

Follow-Up

• Reassess within 1 month to document symptom resolution and transition to vestibular rehabilitation when appropriate 1, 2
• Discontinue as soon as possible once acute symptoms subside 1, 2

Adjunctive Lifestyle Modifications

• Limit salt/sodium intake (especially for Ménière's disease) 4, 2
• Avoid excessive caffeine, alcohol, and nicotine 4, 2
• Maintain adequate hydration, regular exercise, and sufficient sleep 4
• Manage stress appropriately 4, 2

Common Pitfalls to Avoid

• Do not prescribe meclizine as primary treatment for BPPV - it does not address the underlying cause and has significantly lower success rates than repositioning maneuvers 1, 2
• Do not use scheduled dosing - this interferes with vestibular compensation 1
• Do not continue long-term - prolonged use delays recovery 1, 4
• Do not ignore fall risk in elderly patients - consider alternatives or very limited use 1, 2
• Do not use vestibular suppressants as continuous therapy for Ménière's disease - reserve for acute attacks only 1, 4, 2