What medications are used to treat acute vertigo attacks in patients with Meniere disease or vestibular neuritis?

Acute Vertigo Management in Meniere Disease and Vestibular Neuritis

For acute vertigo attacks in both Meniere disease and vestibular neuritis, use short-term vestibular suppressants (meclizine 25-100 mg daily or benzodiazepines) combined with antiemetics (prochlorperazine 5-10 mg) for no more than 3-5 days, then discontinue to allow vestibular compensation. 1

Medication Selection for Acute Attacks

First-Line Vestibular Suppressants

• Meclizine is the most commonly used antihistamine for peripheral vertigo, working by suppressing the central emetic center, and should be used primarily as-needed (PRN) rather than on a scheduled basis 1

• The FDA approves meclizine specifically for treatment of vertigo associated with vestibular system diseases in adults 2

• Typical dosing is 25-100 mg daily during acute attacks only 1

• Benzodiazepines (such as diazepam 10 mg IM once or twice daily) may be used for short-term management of severe vertigo symptoms and can help with psychological anxiety secondary to vertigo 1, 3

Antiemetic Therapy

• Prochlorperazine is the preferred antiemetic for severe nausea and vomiting associated with vertigo, with dosing of 5-10 mg orally or intramuscularly every 6 hours, maximum 3 doses per 24 hours 1
• Prochlorperazine is more effective and better tolerated than metoclopramide, with less sedation and higher bioavailability 1

Alternative Options

• Scopolamine (transdermal) should only be used for short-term management during acute attacks, though it is not commonly prescribed due to significant adverse effects including blurred vision, dry mouth, dilated pupils, urinary retention, and sedation 4

Disease-Specific Considerations

Meniere Disease

• Vestibular suppressants should only be offered during acute attacks, not as continuous therapy 1
• Long-term management relies on dietary modifications (salt restriction to 1500-2300 mg daily) and diuretics rather than vestibular suppressants 1, 4
• Betahistine showed no significant benefit over placebo in reducing vertigo attack frequency in the 2020 BEMED trial 1

Vestibular Neuritis

• Oral corticosteroids accelerate recovery of peripheral vestibular function when started within 3 days of onset 5
• Antiemetics and vestibular suppressants are useful acutely but should be withdrawn as soon as possible (preferably after the first several days) because prolonged use impedes central vestibular compensation 5

Critical Duration Limitations

Vestibular suppressants must be limited to 3-5 days maximum because:

• Long-term use interferes with central vestibular compensation and prolongs recovery 1, 6
• These medications are a significant independent risk factor for falls, especially in elderly patients 1, 4
• Prolonged use can cause drowsiness, cognitive deficits, and interference with driving 1

Treatment Algorithm

1. Days 1-3 of acute attack:

   • Start meclizine 25-100 mg daily PRN or benzodiazepine 1
   • Add prochlorperazine 5-10 mg for severe nausea/vomiting 1
   • For vestibular neuritis: consider oral corticosteroids if presenting within 3 days 5

2. Days 4-5:

   • Begin tapering vestibular suppressants 1
   • Encourage early resumption of normal activity to promote compensation 5

3. After day 5:

   • Discontinue all vestibular suppressants 1
   • Transition to vestibular rehabilitation therapy 1, 6

4. Follow-up at 1 month:

   • Reassess for symptom resolution or persistence 1
   • Document need for further intervention 1

Common Pitfalls to Avoid

• Do not prescribe vestibular suppressants on a scheduled basis - use PRN dosing to avoid interfering with compensation 1
• Do not continue vestibular suppressants beyond 5 days - this delays recovery and increases fall risk 1, 6
• Do not use vestibular suppressants during vestibular rehabilitation - medications impede the compensation process 1
• Do not use meclizine as primary treatment for BPPV - it masks symptoms without addressing the underlying cause 6

Special Populations

Elderly Patients with Cardiovascular Disease

• Monitor for drug-drug interactions with cardiovascular medications 1
• Educate about postural hypotension risk before prescribing vestibular suppressants 1
• Consider deprescribing other medications that contribute to fall risk 1
• Age-related pharmacokinetic changes affect drug metabolism and clearance 1

Adjunctive Non-Pharmacological Management

• Limit salt/sodium intake to 1500-2300 mg daily 4, 6
• Avoid excessive caffeine, alcohol, and nicotine 1, 4
• Maintain adequate hydration, regular exercise, and sufficient sleep 1, 4
• Implement stress management techniques 1, 4
• Begin vestibular rehabilitation therapy after acute phase resolves 1, 6