Can Wellbutrin (bupropion) cause dizziness in adults, particularly those with a history of neurological disorders or cardiovascular diseases?

Can Wellbutrin Cause Dizziness?

Yes, Wellbutrin (bupropion) causes dizziness in 5-11% of patients, with the incidence increasing at higher doses, and this risk is particularly relevant in patients with neurological or cardiovascular conditions who may be more vulnerable to this adverse effect. 1

Evidence from FDA Drug Labeling

The FDA-approved prescribing information for bupropion clearly documents dizziness as a dose-dependent adverse reaction 1:

• At 300 mg/day: 5% of patients experienced dizziness
• At 400 mg/day: 7% of patients experienced dizziness
• At sustained-release formulations: 11% of patients experienced dizziness 1

This represents a clinically significant incidence that exceeds placebo rates and warrants patient counseling before initiating therapy.

Additional Central Nervous System Effects

Bupropion produces a constellation of CNS adverse effects beyond dizziness that may compound the risk in vulnerable populations 1:

• Insomnia (6-16%) - dose-dependent and most common neurological side effect
• Agitation (2-9%) - increases with dose escalation
• Tremor (1-6%) - particularly at higher doses
• Anxiety (3-6%) - may exacerbate pre-existing anxiety disorders
• Vertigo - reported in postmarketing surveillance 1

Special Considerations for High-Risk Populations

Patients with Cardiovascular Disease

Bupropion can cause cardiovascular effects that may indirectly contribute to dizziness 1, 2:

• Postural hypotension - documented in postmarketing reports, increasing fall risk
• Hypertension - paradoxically can also occur (0-2% incidence)
• Tachycardia/palpitations - may cause lightheadedness
• Syncope - rare but documented in postmarketing surveillance 1

In patients with pre-existing cardiovascular disease, monitor blood pressure (both sitting and standing) during initial titration and dose escalations. 2

Patients with Neurological Disorders

The combination of bupropion with pre-existing neurological conditions requires heightened vigilance 2:

• Seizure risk is dose-dependent - doses ≥450 mg/day carry increased risk, with documented seizures occurring even at therapeutic doses of 600 mg/day 3
• Cognitive impairment - can manifest as confusion, memory problems, or altered mental status 2
• Extrapyramidal symptoms - including dystonia and akathisia in postmarketing reports 1

Bupropion is contraindicated in patients with seizure disorders, and caution is warranted in those with conditions that lower seizure threshold (e.g., traumatic brain injury, stroke, CNS tumors). 2

Clinical Management Strategies

Dose Titration to Minimize Dizziness

Start at lower doses and titrate gradually 2:

• Begin with 150 mg once daily for 1 week
• Increase to 300 mg/day (divided doses for immediate-release, once daily for extended-release)
• Maximum dose should not exceed 450 mg/day to minimize seizure and dizziness risk
• In elderly or medically compromised patients, consider even slower titration 2

Monitoring Parameters

Implement systematic monitoring during the first 4-8 weeks 2, 1:

• Orthostatic vital signs - check blood pressure sitting and standing, particularly in elderly patients or those on antihypertensives
• Symptom diary - have patients track dizziness episodes, timing, and severity
• Fall risk assessment - especially critical in elderly patients with cardiovascular or neurological comorbidities
• Concomitant medications - review for drug interactions that may potentiate dizziness (antihypertensives, benzodiazepines, other CNS-active agents) 2, 4

Drug Interactions That Increase Dizziness Risk

Avoid or use extreme caution when combining bupropion with 2, 4:

• MAO inhibitors - contraindicated; allow ≥14 days between discontinuation
• Benzodiazepines - significantly increase sedation and dizziness risk, particularly during initial titration 4
• Antihypertensives - may potentiate orthostatic hypotension
• Other CNS-active medications - including antipsychotics, which can compound neurological side effects 4, 5

When Dizziness Signals More Serious Complications

Dizziness accompanied by the following symptoms requires immediate evaluation 1, 6:

• "Jittery"/anxious/agitated state - present in 83% of patients who subsequently developed seizures in therapeutic error cases 6
• Tachycardia or palpitations - may herald cardiovascular instability
• Tremor or muscle twitching - can precede seizure activity
• Confusion or altered mental status - suggests possible toxicity even at therapeutic doses 7

These warning signs typically appear within 2-8 hours of dose escalation and warrant dose reduction or discontinuation. 6

Practical Clinical Pitfalls to Avoid

• Do not dismiss early dizziness as "transient" - while some tolerance may develop, persistent dizziness (>2 weeks) suggests the dose is too high or the patient is intolerant 2
• Do not combine with alcohol - significantly worsens cognitive impairment and dizziness 2
• Do not abruptly discontinue high doses (≥300 mg/day) - taper over at least 1 week to avoid withdrawal symptoms 2
• Do not ignore patient reports of "feeling off-balance" - this may be prodromal to more serious neurological effects 6

Comparison with Combination Formulations

When bupropion is combined with naltrexone (Contrave), dizziness remains a prominent adverse effect (reported in the COR trials), alongside nausea, headache, and constipation 2. The naltrexone component does not appear to significantly modify the dizziness profile compared to bupropion monotherapy.