When do you prescribe medications for dizziness in patients with varying underlying causes, such as Benign Paroxysmal Positional Vertigo (BPPV), labyrinthitis, or vestibular neuritis, and what factors do you consider, including age, medical history, and symptoms?

When to Prescribe Medications for Dizziness

Medications for dizziness should be prescribed only for short-term management of severe nausea and vomiting in acutely symptomatic patients, not for routine treatment of the underlying vestibular disorder itself. 1

Primary Treatment Approach: Physical Maneuvers, Not Medications

The evidence is unequivocal that canalith repositioning procedures (Epley maneuver) are first-line treatment for BPPV with 80-93% success rates, while medications alone achieve only 30.8% improvement at 2-week follow-up. 1 Vestibular suppressant medications are not routinely recommended for treatment of BPPV or most peripheral vestibular disorders because they:

• Produce drowsiness, cognitive deficits, and interference with driving 1
• Significantly increase fall risk, especially in elderly patients taking multiple medications 1
• Prevent central compensation and delay recovery 1
• Show no additional symptom relief compared to placebo in controlled trials 1

Patients who underwent the Epley maneuver alone recovered faster than those who received both the Epley maneuver and labyrinthine sedatives concurrently. 1

Specific Indications for Medication Use

Short-Term Antiemetic Use (Acceptable)

Prescribe antiemetics only for:

• Severe nausea or vomiting in acutely symptomatic patients who cannot tolerate physical examination or treatment 1
• Prophylaxis before performing Dix-Hallpike maneuvers in patients with prior severe nausea/vomiting during testing 1
• Patients who refuse therapy but are severely symptomatic 1
• Post-procedure severe symptoms after canalith repositioning 1

Examples: Dimenhydrinate 50 mg every 4 hours as needed for nausea 2, or meclizine for acute symptom control 3, 4

Limited Benzodiazepine Use (Selective)

Benzodiazepines may decrease functional and emotional (but not physical) scores on the Dizziness Handicap Inventory when added to canal repositioning maneuvers, suggesting a role only in treating psychological anxiety secondary to BPPV—not the vertigo itself. 1

Betahistine (Highly Selective)

Betahistine showed effectiveness only in patients meeting all of these criteria when used with canal repositioning maneuvers: 1

• Age >50 years
• Hypertension present
• Symptom onset <1 month
• Brief attacks <1 minute duration

Corticosteroids for Vestibular Neuritis

Corticosteroids are indicated for acute vestibular neuritis (not BPPV), though they are significantly underutilized in practice—only 1-2% of patients receive them despite evidence supporting their use. 3, 4

Conditions Where Medications Are NOT Indicated

Do not prescribe vestibular suppressants for:

• BPPV with typical presentation—treat with Epley maneuver instead 1, 5
• Routine management of any vestibular disorder 1
• Long-term use in any vestibular condition 1
• Vestibular rehabilitation candidates—medications interfere with central compensation 1, 6

Disease-Specific Medication Approaches

Ménière's Disease

• Salt restriction and diuretics are first-line 5
• Intratympanic dexamethasone or gentamicin for refractory cases 7, 4
• Betahistine may be considered 4

Vestibular Migraine

• Migraine prophylaxis (metoprolol, topiramate) and lifestyle modifications 5, 4
• Not vestibular suppressants 5

Vestibular Neuritis/Labyrinthitis

• Corticosteroids for acute phase 3, 4
• Vestibular rehabilitation as primary intervention 5, 6
• Short-term vestibular sedatives only for severe acute symptoms 4

Critical Counseling When Medications Are Prescribed

When vestibular suppressants are prescribed for the specific indications above, mandatory counseling must include: 1

• Increased rates of cognitive dysfunction
• Significantly elevated fall risk, especially with polypharmacy
• Drug interactions potential
• Increased risk of driving and machinery accidents
• Time-limited use only—typically days, not weeks

Reassessment Requirements

Reassess all patients within 1 month after initial treatment to document resolution or persistence of symptoms. 1 Patients with continued symptoms remain at risk for falls and decreased quality of life, requiring alternative management strategies rather than continued medication use. 1

Common Prescribing Pitfalls to Avoid

• Prescribing meclizine for diagnosed BPPV—58% of patients receive this despite lack of indication 3
• Failing to perform Epley maneuver and defaulting to medication instead 3
• Long-term vestibular suppressant use—prevents central compensation 1, 6
• Polypharmacy in elderly patients—exponentially increases fall risk 1
• Using medications as substitute for proper diagnostic maneuvers 3