What medications are used to treat dizziness in a patient with potential underlying conditions such as inner ear problems, vestibular migraines, or orthostatic hypotension?

Medications for Treating Dizziness

Vestibular suppressants should be used only for short-term management during acute vertigo attacks, not for chronic dizziness, as prolonged use delays central compensation and increases fall risk. 1, 2

Acute Vertigo Episodes

Antihistamines

• Meclizine is FDA-approved for treating vertigo associated with vestibular system diseases 3
• Dimenhydrinate can be used during acute attacks 1
• These agents should be limited to a brief course only during active symptoms 1, 2

Benzodiazepines

• Used cautiously for severe acute vertigo to alleviate both vertigo and associated anxiety 1, 2
• Significant risk of dependency with prolonged use 1
• Independent risk factor for falls, especially dangerous in elderly patients when combined with other medications 4, 2

Maintenance Therapy for Meniere's Disease

Diuretics

• Primary maintenance option for Meniere's disease to modify electrolyte balance in the endolymph and reduce its volume 1
• More reliable than betahistine based on recent evidence 1

Betahistine

• A histamine analogue that increases vasodilation to the inner ear 1
• Recent high-quality evidence (BEMED trial) showed no significant difference versus placebo, making its efficacy questionable 1

Critical Warnings About Medication Use

When NOT to Use Vestibular Suppressants

• Avoid routine use for BPPV—they are inferior to repositioning maneuvers (Epley maneuver shows 93.3% improvement versus 30.8% with medication alone) 4
• Do not use during vestibular rehabilitation—prolonged use interferes with central compensation and delays recovery 2
• Not recommended for chronic imbalance between attacks 1

Medications NOT Recommended

• Positive pressure therapy (Meniett device) shows no significant difference compared to placebo for Meniere's disease 1
• Antivirals (aciclovir, valacyclovir) should not be routinely prescribed for viral labyrinthitis, as multiple RCTs failed to demonstrate benefit 2
• Antibiotics should not be routinely prescribed for typical viral labyrinthitis 2

Condition-Specific Medication Approaches

Vestibular Migraine

• Prophylactic agents are the mainstay: calcium channel antagonists (L-channel blockers), tricyclic antidepressants, and beta-blockers 5

Intratympanic Therapies for Refractory Meniere's Disease

• Intratympanic steroids for patients not responsive to non-invasive treatment (85-90% improvement in vertigo symptoms) 1
• Intratympanic gentamicin for patients who failed conservative therapies (73.6% complete vertigo control rate) 1
• These carry risks including hearing loss and tympanic membrane perforation 1

Key Clinical Pitfalls

• Titrate down or stop medications once symptoms subside rather than continuing indefinitely 1
• Avoid polypharmacy in elderly patients—vestibular suppressants combined with other medications significantly increase fall risk 2
• Consider comorbidities (renal/cardiac disease, asthma) that may contraindicate certain medications 1
• Reassess within 1 month after initial treatment to document resolution or persistence and adjust therapy if control is inadequate 4