Can Stemetil (prochlorperazine) be used to treat severe nausea, vomiting and vertigo in a healthy adult with acute vestibular neuritis, and what is the appropriate dose and duration?

Can Stemetil (Prochlorperazine) Be Used for Acute Vestibular Neuritis?

Yes, prochlorperazine (Stemetil) can be used for short-term management of severe nausea and vomiting in acute vestibular neuritis, but only for 3–5 days maximum and should not be used as primary treatment for the vertigo itself. 1

Appropriate Use in Vestibular Neuritis

Prochlorperazine is specifically recommended for severe nausea and vomiting associated with acute vestibular attacks, not for treating the underlying vestibular dysfunction. 1 The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that vestibular suppressants should be used for short-term symptom control rather than definitive treatment. 1

Dosing and Duration

• Recommended dose: 5–10 mg orally or intramuscularly every 6 hours, maximum 3 doses per 24 hours 1
• Maximum treatment duration: 3–5 days only 1
• Treatment should be withdrawn as soon as possible, preferably after the first several days, to avoid interfering with central vestibular compensation 1, 2

Clinical Context for Vestibular Neuritis

Vestibular neuritis presents with severe vertigo, intense nausea, and vomiting that can be disabling in the acute phase. 3, 4 In this setting, prochlorperazine's potent antiemetic effect on both central and peripheral dopaminergic receptors makes it appropriate for managing the autonomic symptoms. 1 A large prospective study of 1,716 patients with acute peripheral vertigo (including 17.4% with vestibular neuritis) demonstrated that 91.1% showed clinical improvement with prochlorperazine, with excellent tolerability. 5

Critical Limitations and Cautions

When to Stop Immediately

• Discontinue prochlorperazine before starting vestibular rehabilitation therapy, as it impedes the central compensation process essential for long-term recovery 1, 2
• Do not use beyond 5 days, as prolonged use interferes with vestibular compensation and increases fall risk 1, 2

Important Safety Concerns

• Risk of extrapyramidal symptoms (akathisia): Monitor patients for 48 hours post-administration; treat with diphenhydramine if akathisia develops 6
• Fall risk: Prochlorperazine is an independent risk factor for falls, especially in elderly patients 1
• Cognitive impairment and drowsiness: Can affect driving and daily functioning 1
• Contraindications: Avoid in patients with CNS depression, concurrent adrenergic blocker use, severe hypotension, or psychiatric history 1

Definitive Treatment Algorithm

Days 1–5 (Acute Phase)

• Use prochlorperazine 5–10 mg every 6 hours (maximum 3 doses/24 hours) only if nausea/vomiting is severe and disabling 1
• Symptomatic medication is indicated only during the acute phase to relieve nausea and vomiting 4

Days 3–7 (Early Recovery)

• Begin vestibular rehabilitation exercises as soon as acute symptoms subside, usually within the first week 1
• Stop prochlorperazine before initiating vestibular rehabilitation 1, 2

Week 4 (Follow-up)

• Reassess within 1 month to document symptom resolution or persistence 1, 7
• Transition focus entirely to vestibular rehabilitation for long-term recovery 1

Why Vestibular Rehabilitation Is Primary Treatment

Vestibular rehabilitation achieves long-term recovery rates comparable to corticosteroid therapy, with approximately 45% of patients attaining complete symptom resolution at 12 months. 1 Across 21 randomized trials, vestibular rehabilitation showed no serious adverse events and is more effective than prolonged medication use for sustained symptom control. 1, 7

Common Pitfalls to Avoid

• Do not use prochlorperazine as continuous therapy: It addresses symptoms, not the underlying vestibular dysfunction 1, 4
• Do not delay vestibular rehabilitation: Early initiation (within first week) is critical for optimal recovery 1
• Do not prescribe for mild symptoms: Reserve for severe, disabling nausea/vomiting only 1
• Do not use in elderly patients without careful fall risk assessment: Consider deprescribing other fall-risk medications when adding prochlorperazine 1

Alternative Considerations

If prochlorperazine is contraindicated or poorly tolerated, meclizine 25–100 mg as-needed is an alternative vestibular suppressant, though it should also be limited to short-term use. 1, 7 For patients requiring sedation alongside antiemetic effects, promethazine may be considered, though it carries higher sedation risk. 6