What should be done for a patient who has been taking Stugeron Forte (cinnarizine) for two days and still experiences dizziness?

What to Do When Stugeron Forte (Cinnarizine) Fails After 2 Days

If dizziness persists after 2 days of Stugeron Forte, stop the medication and immediately pursue definitive diagnosis to identify the underlying cause—cinnarizine is only appropriate for short-term symptomatic relief and should never be used as primary treatment without knowing the specific vestibular disorder.

Immediate Action Steps

Stop Cinnarizine and Reassess the Diagnosis

• Cinnarizine should not be continued beyond short-term use (typically 5-7 days) without establishing a specific diagnosis, as prolonged vestibular suppressant use impairs central nervous system compensation and delays recovery 1, 2
• The lack of response after 2 days strongly suggests either:
  • Wrong diagnosis (not a condition responsive to vestibular suppressants)
  • Inappropriate use of medication as primary treatment when specific interventions are needed
  • A more serious underlying condition requiring urgent evaluation 3

Determine the Type of Dizziness

• First, clarify whether the patient has true vertigo (spinning sensation) versus non-specific dizziness (lightheadedness, imbalance), as this fundamentally changes management 3
• True vertigo suggests vestibular pathology, while vague dizziness may indicate cardiovascular, neurologic, or other systemic causes 3
• Ask specifically about:
  • Duration of episodes (seconds = BPPV; minutes to hours = Ménière's or vestibular migraine; days = vestibular neuritis) 3
  • Triggers (positional changes = BPPV; spontaneous = other causes) 3
  • Associated symptoms (hearing loss, tinnitus, aural fullness = Ménière's; headache/photophobia = vestibular migraine) 3

Diagnosis-Specific Management

If BPPV is Suspected (Brief Positional Vertigo <1 Minute)

• Perform canalith repositioning maneuvers (Epley or Semont) immediately—this is the definitive treatment with 78.6-93.3% success rates, compared to only 30.8% with medication alone 1, 2
• Cinnarizine has no role as primary BPPV treatment and should only be used briefly for severe nausea during repositioning procedures 1, 2
• Common pitfall: Continuing vestibular suppressants for BPPV delays recovery and increases fall risk, especially in elderly patients 1, 2

If Ménière's Disease is Suspected (Episodes Lasting 20 Minutes to Hours with Hearing Symptoms)

• Cinnarizine may provide short-term relief during acute attacks but does not prevent future episodes 1, 4
• Transition to definitive management:
  • Dietary sodium restriction to 1500-2300 mg daily 1
  • Consider diuretics for maintenance therapy 1
  • Discontinue cinnarizine after the acute attack resolves (typically within days) 1, 2

If Vestibular Neuritis is Suspected (Prolonged Vertigo >24 Hours Without Hearing Loss)

• Cinnarizine may be used for 3-5 days maximum during the acute phase 2, 4
• Begin vestibular rehabilitation therapy within 3-7 days of symptom onset—this is more effective than prolonged medication use 1
• Continuing vestibular suppressants beyond the acute phase impairs vestibular compensation and worsens long-term outcomes 1, 2

If Central Causes are Suspected (Stroke, Multiple Sclerosis, Tumor)

• Urgent neurologic evaluation is required if the patient has:
  • Severe imbalance without vertigo
  • Neurologic symptoms (diplopia, dysarthria, dysphagia, facial numbness, weakness)
  • Sudden onset with cardiovascular risk factors
  • Progressive or persistent symptoms 3
• Cinnarizine showed poor efficacy for central neurologic disorders in clinical trials 4

Why Cinnarizine May Not Be Working

Limited Efficacy Profile

• Cinnarizine demonstrated favorable results primarily in sudden peripheral vestibular deficit, circulatory vertigo, and post-traumatic vertigo 4
• Results were less conclusive for Ménière's disease and poor for central neurologic disorders 4
• Even in responsive conditions, only 60% of patients (12/20) showed satisfactory improvement versus 25% with placebo 4

Inappropriate Use as Monotherapy

• Cinnarizine acts as a vestibular suppressant but does not address underlying pathology 1, 2, 5
• For conditions requiring specific interventions (BPPV, Ménière's maintenance), medication alone is insufficient 1, 2

Critical Safety Considerations

Risks of Continued Use

• Vestibular suppressants significantly increase fall risk, especially in elderly patients 1, 2
• Drowsiness was the most common side effect (26% of patients in one study) 4
• Prolonged use delays vestibular compensation and worsens long-term recovery 1, 2
• Anticholinergic effects can cause cognitive impairment, urinary retention, and constipation 2

When to Seek Urgent Care

• Severe imbalance with inability to walk
• New neurologic symptoms (weakness, speech changes, vision changes)
• Severe headache or neck pain
• Loss of consciousness or confusion
• Cardiovascular symptoms (chest pain, palpitations) 3

Recommended Algorithm

1. Stop cinnarizine after 2 days of no improvement
2. Perform Dix-Hallpike test to rule out BPPV—if positive, perform Epley maneuver 1, 2
3. If not BPPV, obtain detailed history focusing on episode duration, triggers, and associated symptoms 3
4. Consider specialist referral (ENT or neurology) for:
   • Persistent symptoms beyond 1 week
   • Recurrent episodes
   • Associated hearing loss or neurologic symptoms 3, 1
5. Transition to vestibular rehabilitation therapy within 3-7 days for most vestibular conditions 1

Common pitfall: Continuing vestibular suppressants indefinitely without establishing a diagnosis leads to medication dependence, delayed recovery, increased fall risk, and missed opportunities for definitive treatment 1, 2.