What medications are recommended for a patient experiencing vertigo?

Medications for Vertigo

For most patients with vertigo, medications should be used only for short-term symptomatic relief (3-5 days maximum) rather than as primary treatment, with meclizine 25-100 mg daily being the first-line option for acute peripheral vertigo, while BPPV requires canalith repositioning maneuvers instead of medications. 1

Treatment Algorithm Based on Vertigo Type

Benign Paroxysmal Positional Vertigo (BPPV)

• Do NOT use medications as primary treatment for BPPV - the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine vestibular suppressants like meclizine for BPPV 1
• Canalith repositioning maneuvers (Epley, Semont) achieve 78.6%-93.3% improvement compared to only 30.8% with medication alone 1
• Meclizine may only be considered in very limited circumstances: severe nausea/vomiting during acute symptoms, prophylaxis before repositioning maneuvers in patients with prior severe nausea, or when patients refuse other treatments 1

Acute Peripheral Vertigo (Vestibular Neuritis, Labyrinthitis)

• Meclizine 25-100 mg daily in divided doses is the most commonly used first-line medication for short-term symptom control 1, 2
• Use as-needed (PRN) rather than scheduled dosing to avoid interfering with vestibular compensation 1
• Limit duration to 3-5 days maximum, as prolonged use delays central compensation 3
• For severe nausea/vomiting, add prochlorperazine 5-10 mg orally or IV, maximum 3 doses per 24 hours 3
• For severe anxiety component, consider short-term benzodiazepines (e.g., diazepam 10 mg) 3, 4

Ménière's Disease

• Vestibular suppressants (meclizine or benzodiazepines) should only be used during acute attacks, NOT as continuous therapy 1, 3
• Betahistine showed NO significant benefit over placebo in the 2020 BEMED trial for reducing attack frequency over 9 months 3
• Long-term management relies on dietary salt restriction (1500-2300 mg daily) and diuretics, not medications 1, 5

Medication-Specific Guidance

Meclizine (First-Line)

• FDA-approved dosing: 25-100 mg daily in divided doses 2
• Mechanism: Suppresses central emetic center through antihistamine action 3
• Major caution: Anticholinergic side effects (drowsiness, cognitive deficits, dry mouth, blurred vision, urinary retention) are particularly problematic in elderly patients 1
• Use with caution in patients with asthma, glaucoma, or prostate enlargement 2
• Significantly increases fall risk in elderly patients - consider avoiding in this population 1, 5

Prochlorperazine (For Severe Nausea)

• Dosing: 5-10 mg orally or IV, maximum 3 doses per 24 hours 3
• More effective than metoclopramide for vertigo-associated nausea with better tolerability 3
• Contraindications: CNS depression, concurrent adrenergic blockers, severe hypotension, psychiatric history (risk of extrapyramidal symptoms) 3
• Not for primary vertigo treatment - only for managing severe nausea/vomiting 1, 3

Benzodiazepines (For Severe Symptoms with Anxiety)

• May help with both vestibular suppression and psychological anxiety secondary to vertigo 1, 3
• Use only for short-term management during acute severe attacks 3
• Increases CNS depression when combined with other sedatives or alcohol 2

Critical Warnings and Common Pitfalls

What NOT to Do

• Never use vestibular suppressants during vestibular rehabilitation therapy - medications impede the compensation process 3
• Never prescribe meclizine long-term - interferes with central vestibular compensation and prolongs recovery 1, 5
• Never use medications as primary treatment for BPPV - success rates are dramatically lower than repositioning maneuvers 1
• Avoid continuous therapy in Ménière's disease - use only during acute attacks 3

Safety Considerations

• All vestibular suppressants cause drowsiness - warn patients against driving or operating machinery 2
• Elderly patients are at particularly high risk for falls, cognitive impairment, and anticholinergic burden 1, 5
• Avoid alcohol and other CNS depressants during treatment 2
• Monitor for drug interactions with CYP2D6 inhibitors when using meclizine 2

When Medications Worsen Vertigo

• If meclizine worsens symptoms, discontinue immediately - it may be interfering with vestibular compensation 5
• Reassess the diagnosis, as BPPV requires repositioning maneuvers, not medications 5
• Consider transitioning to vestibular rehabilitation therapy instead 5

Follow-Up and Transition Strategy

• Reassess within 1 month to document symptom resolution or persistence 1, 3
• Transition from medications to vestibular rehabilitation therapy as soon as acute symptoms subside to promote long-term recovery 3, 5
• Discontinue vestibular suppressants as quickly as possible, preferably after the first several days 3
• Implement lifestyle modifications: salt restriction, avoid caffeine/alcohol/nicotine, adequate hydration, regular exercise, stress management 1, 5