Can I give betahistine to a 34‑year‑old woman with brief position‑triggered vertigo, nausea, transient visual scintillations and a partially positive Epley maneuver consistent with benign paroxysmal positional vertigo?

Betahistine Is Not Recommended for BPPV

Do not prescribe betahistine for this patient with BPPV—the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine treatment of BPPV with vestibular suppressant medications, including betahistine. 1, 2

Why Betahistine Should Not Be Used

Guideline-Based Contraindication

• The AAO-HNS clinical practice guideline states that vestibular suppressants (including betahistine) should not be routinely used for BPPV because they do not address the underlying mechanical problem of displaced otoconia in the semicircular canals. 1, 2
• There is no evidence that vestibular suppressant medications are effective as definitive or primary treatment for BPPV. 2
• The most recent high-quality evidence (BEMED trial, 2020) showed betahistine had no significant benefit over placebo in reducing vertigo attack frequency over 9 months. 2

Superior Alternative Treatment

• Canalith repositioning maneuvers (Epley or Semont) achieve 78.6-93.3% improvement rates compared to medication alone which shows only 30.8% improvement. 2
• The Epley maneuver has approximately 80% success with only 1-3 treatments, making it far more effective than any medication. 2, 3
• Patients who underwent the Epley maneuver alone recovered faster than those who received concurrent vestibular suppressants. 2

The Correct Treatment Approach

First-Line: Canalith Repositioning

• Perform the Epley maneuver immediately—this is the definitive treatment for posterior canal BPPV (the most common type). 1, 2
• The partially positive Epley test in this patient confirms posterior canal involvement and indicates the maneuver is both diagnostic and therapeutic. 1
• Alternative repositioning procedures (Semont maneuver) have similar success rates if the patient cannot tolerate the Epley. 2

Managing Nausea During the Procedure

• For the nausea this patient is experiencing, counsel her that intense vertigo and nausea during the maneuver typically subside within 60 seconds. 2
• If she has severe nausea during repositioning, consider prochlorperazine 5-10 mg for short-term symptomatic relief of nausea only—not as treatment for the BPPV itself. 2, 4
• Meclizine 25-50 mg may be used as prophylaxis only if she has previously experienced severe nausea during repositioning maneuvers. 2

When Observation Is Appropriate

• BPPV resolves spontaneously in approximately 20% of patients by 1 month and up to 50% at 3 months, so observation with follow-up is a reasonable option if symptoms are mild. 1
• However, given her symptomatic presentation with nausea, active treatment with repositioning is preferred over observation. 1

Critical Pitfalls to Avoid

Why Betahistine Appears in the Literature

• Some older studies suggest betahistine may reduce residual dizziness after successful repositioning, but this is distinct from treating acute BPPV. 2, 5
• A 2025 meta-analysis showed betahistine combined with Epley showed no clinically significant difference at 1 week, with only marginal VAS score improvement at 4 weeks—not clinically meaningful for acute management. 6
• Betahistine's role is primarily in Ménière's disease (though even this is questioned by recent trials), not BPPV. 2, 7

Medication Risks in This Young Patient

• Vestibular suppressants cause drowsiness and cognitive deficits that interfere with driving and daily activities—particularly problematic for a 34-year-old likely working and driving. 2, 4
• These medications can interfere with central vestibular compensation, potentially prolonging recovery. 2, 4
• They increase fall risk, which compounds the already elevated fall risk from untreated BPPV. 2, 3

Follow-Up Plan

• Reassess within 1 week after the Epley maneuver to document symptom resolution. 2, 4
• If symptoms persist, repeat the repositioning maneuver—success often requires 1-3 treatments. 2
• If residual mild imbalance persists after successful repositioning (negative provocation test), consider vestibular rehabilitation exercises rather than medication. 2, 4
• Only if she refuses repositioning maneuvers entirely would medication be considered, and even then, betahistine is not the preferred agent. 2

Addressing the Visual Scintillations

• The transient visual scintillations warrant consideration of vestibular migraine as a comorbid or alternative diagnosis, though this does not change the immediate management of confirmed BPPV. 1
• If symptoms persist after successful BPPV treatment, further evaluation for migraine-associated vertigo may be indicated, but this is a separate clinical question. 1