What are the treatment options for a patient with acute vestibular symptoms, considering their medical history and potential allergies?

Acute Vestibular Suppressant Options

For acute vestibular symptoms, offer a limited course of vestibular suppressants—specifically meclizine 25-100 mg daily in divided doses or benzodiazepines (diazepam 10 mg)—for short-term symptom control only during severe attacks, typically for no more than 3-5 days, as prolonged use interferes with central vestibular compensation and increases fall risk. 1, 2, 3

First-Line Vestibular Suppressants

Meclizine (Antihistamine)

• FDA-approved dosing: 25-100 mg daily orally in divided doses depending on symptom severity 3
• Works by suppressing the central emetic center to relieve nausea and vertigo 2
• Should be used primarily as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 2
• Most commonly prescribed antihistamine for peripheral vertigo in clinical practice 2

Benzodiazepines

• Diazepam 10 mg IM once or twice daily for severe acute symptoms 4
• Useful for managing severe vertigo symptoms and psychological anxiety secondary to vertigo 2
• More sedating than antihistamines but effective for acute symptom control 2

Second-Line Options for Severe Nausea/Vomiting

Prochlorperazine (Phenothiazine)

• Dosing: 5-10 mg orally or IV, maximum three doses per 24 hours 2
• Reserved for short-term management of severe nausea/vomiting associated with vertigo, not primary vertigo treatment 2
• Use with caution in patients with CNS depression, psychiatric history (risk of extrapyramidal symptoms), or concurrent adrenergic blocker use 2
• Contraindicated in severe hypotension 2

Promethazine (Phenothiazine with Antihistamine Properties)

• Dosing: 12.5-25 mg for severe cases requiring rapid onset 5
• Side effects include hypotension, respiratory depression, and extrapyramidal effects 5

Alternative Combination Therapy (Less Common in US)

Cinnarizine/Dimenhydrinate Fixed Combination

• Cinnarizine 20 mg + dimenhydrinate 40 mg three times daily showed superior efficacy to monotherapy in research studies 6, 7
• Significantly more effective than betahistine for acute vestibular vertigo 7
• Note: Cinnarizine is not FDA-approved in the United States but is available in other countries 6

Critical Cautions and Contraindications

Significant Harms of Prolonged Use

• Vestibular suppressants are an independent risk factor for falls, especially in elderly patients 2
• Long-term use interferes with central vestibular compensation, delaying recovery 2, 8
• Causes drowsiness, cognitive deficits, and impairs driving ability 2, 3
• Should be withdrawn as soon as possible, preferably after the first several days 8

When NOT to Use Vestibular Suppressants

• Do NOT use for BPPV (benign paroxysmal positional vertigo): The American Academy of Otolaryngology explicitly recommends against routine meclizine use for BPPV, as canalith repositioning (Epley maneuver) is definitive treatment with 80% resolution versus 30.8% with medication 9
• Do NOT use for chronic/ongoing management: Only indicated during acute attacks, not as continuous therapy 1, 2
• Do NOT use during vestibular rehabilitation: Medications impede the compensation process 1, 8

Meclizine-Specific Precautions

• Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 3
• Avoid concurrent alcohol use (increased CNS depression) 3
• Monitor for drug interactions with CYP2D6 inhibitors 3
• Contraindicated in patients with hypersensitivity to meclizine 3

Treatment Algorithm

For acute vestibular symptoms:

1. Assess severity and type of vertigo:

   • If positional vertigo with head movement provocation → Perform Epley maneuver, NOT medication 9
   • If spontaneous acute vertigo with severe symptoms → Proceed to step 2

2. Initiate short-term vestibular suppressant:

   • Meclizine 25-50 mg orally 2-3 times daily PRN for mild-moderate symptoms 2, 3
   • Diazepam 10 mg IM for severe symptoms with significant anxiety 4

3. Add antiemetic if severe nausea/vomiting:

   • Prochlorperazine 5-10 mg orally/IV (maximum 3 doses/24 hours) 2
   • Screen for contraindications (psychiatric history, severe hypotension, CNS depression) 2

4. Limit duration to 3-5 days maximum:

   • Taper and discontinue as soon as acute symptoms improve 2, 8
   • Transition to vestibular rehabilitation for ongoing symptoms 1, 8

5. Reassess within 1 month:

   • Document symptom resolution or persistence 2
   • If symptoms persist, refer for vestibular rehabilitation rather than continuing medication 1, 8

Special Considerations for Ménière's Disease

• Vestibular suppressants should only be offered during acute attacks, not as continuous therapy 1, 2
• Long-term management relies on dietary modifications (salt restriction) and diuretics, not suppressants 2
• Betahistine showed no significant benefit over placebo in the 2020 BEMED trial 2

What to Avoid

• Do NOT prescribe vestibular suppressants for motion sickness prevention: Use scopolamine transdermal patch instead 5
• Do NOT use sotalol or lidocaine for acute vestibular symptoms—these are downgraded/not recommended 1
• Do NOT use amiodarone or digoxin for acute management—no longer recommended 1
• Avoid creating unrealistic expectations: Educate patients that medication provides temporary symptom relief only, not cure 1, 2