From the Guidelines
Benzodiazepines are not recommended for the routine treatment of vertigo, as stated in the 2017 clinical practice guideline update for benign paroxysmal positional vertigo 1. However, if a benzodiazepine is to be used for vertigo, Diazepam (Valium) is generally considered a suitable option, typically prescribed at 2-10 mg doses taken 1-3 times daily as needed for acute vertigo episodes. For severe vertigo attacks, treatment usually lasts only a few days until symptoms subside. Benzodiazepines help with vertigo by enhancing the effect of GABA, an inhibitory neurotransmitter in the brain, which reduces neuronal excitability in the vestibular system. This action suppresses the abnormal signals causing the sensation of spinning or movement. Diazepam is preferred because it has good vestibular suppressant properties and a relatively long half-life, providing sustained relief. Other benzodiazepines like lorazepam (Ativan) or clonazepam (Klonopin) may also be used but are generally considered second-line options. It's essential to note that benzodiazepines should be used short-term due to their potential for dependence and side effects like drowsiness, which may actually increase fall risk in some patients with balance disorders. They work best as part of a comprehensive treatment approach that may include vestibular rehabilitation exercises and addressing the underlying cause of vertigo, as recommended in the guidelines 1. The most recent evidence from 2023 suggests that clonazepam can be used in lower doses for secondary RBD, starting at 0.25 mg, but it is often used with caution due to its potential side effects, including morning sedation, gait imbalance, and cognitive disturbances 1. Given the potential risks and the availability of other treatment options, such as canalith repositioning procedures and vestibular rehabilitation, benzodiazepines should be used judiciously and with careful consideration of the patient's overall condition and potential for adverse effects. Some key points to consider when treating vertigo include:
- The diagnosis of benign paroxysmal positional vertigo (BPPV) should be made based on clinical criteria, including a history of vertigo and a positive Dix-Hallpike test or supine roll test 1.
- Treatment of BPPV should focus on canalith repositioning procedures, such as the Epley maneuver, which have been shown to be effective in resolving symptoms 1.
- Vestibular rehabilitation exercises may also be beneficial in improving balance and reducing symptoms of vertigo 1.
- Benzodiazepines should not be used as a first-line treatment for vertigo due to their potential for dependence and side effects, but may be considered in certain cases where other treatments have failed or are not tolerated 1.
From the Research
Benzodiazepines for Vertigo
- Benzodiazepines are used to treat vertigo, particularly in cases of Ménière's disease and vestibular neuritis 2
- Clonazepam has been shown to be effective in controlling vertigo and tinnitus in patients with cochleovestibular disorders, with 77.4% of vertigo patients achieving complete or substantial control of vertigo 3
- A systematic review and meta-analysis found that single-dose antihistamines provided greater vertigo relief at 2 hours than single-dose benzodiazepines, but daily benzodiazepine use was not associated with improvement in any outcomes for acute vertigo 4
Comparison of Benzodiazepines
- A randomized double-blind placebo-controlled trial found that diazepam and meclizine were equally effective in the treatment of vertigo, with no significant difference in mean change in VAS score from baseline to 60 minutes 5
- Clonazepam has been shown to be a useful and safe drug for the symptomatic treatment of patients suffering from cochleovestibular disorders, with adverse side effects tending to subside with continued therapy 3
Current and Emerging Therapies
- Current medical therapies for dizziness include antihistamines, calcium channel blockers, and benzodiazepines for acute peripheral vertigo, as well as prophylactic pharmacotherapies for specific causes such as Meniere disease and vestibular migraine 6
- Benzodiazepines are not recommended for long-term use due to the potential for dependence and other adverse effects, and are generally used for short-term relief of vertigo symptoms 2, 4