Is there a symptom benefit to discharging a patient with betahistine (Histamine receptor agonist) as needed (prn) for positional vertigo that is gradually improving?

From the Guidelines

There is no evidence to support the use of betahistine as needed (prn) for positional vertigo that is already improving, and it is not recommended as a primary treatment for benign paroxysmal positional vertigo (BPPV) 1.

Key Points to Consider

• The most effective treatments for BPPV are repositioning maneuvers such as the Epley or Semont maneuvers, which physically move displaced calcium crystals back to their proper location in the inner ear.
• Betahistine is primarily used for Meniere's disease and has not been proven effective for BPPV.
• If symptoms persist or worsen, follow up with a healthcare provider who can determine the exact cause of your vertigo and recommend appropriate treatment.

Evidence-Based Recommendations

• The 2017 clinical practice guideline for BPPV recommends against the routine use of vestibular suppressant medications such as antihistamines and/or benzodiazepines for BPPV 1.
• A 2020 study found that betahistine did not change the mean number of vertigo attacks related to Meniere's disease as compared with placebo 1.
• The guideline update group classified the role of patient preference as "none, small, moderate, or large" and recommended that clinicians provide patients with clear and comprehensible information on the benefits to facilitate patient understanding and shared decision making 1.

Treatment Options

• Repositioning procedures such as the Epley or Semont maneuvers are recommended as initial therapy for patients with posterior canal BPPV 1.
• Vestibular rehabilitation, either self-administered or with a clinician, may be offered in the treatment of BPPV 1.
• Observation with follow up may be offered as initial management for patients with BPPV 1.

From the Research

Symptom Benefit of Betahistine for Positional Vertigo

• The effectiveness of betahistine in treating benign paroxysmal positional vertigo (BPPV) has been demonstrated in several studies 2, 3, 4.
• Betahistine has been shown to reduce the severity of vertigo, frequency of attacks, and improve vestibular compensation in patients with BPPV 2, 3.
• A randomized controlled trial found that betahistine add-on therapy to the Epley maneuver resulted in significant improvements in visual analog scale scores and dizziness handicap inventory values compared to the Epley maneuver alone 4.
• Another study suggested that betahistine may facilitate lasting vestibular compensation, with observed effects persisting for 2 months after treatment cessation 5.

Dosage and Treatment Duration

• The recommended daily dose of betahistine for treating peripheral vertigo is 48 mg, with treatment durations ranging from 2-3 months 2, 3, 5.
• A study found that betahistine 48 mg/day for 2 months was effective in treating vertigo, with significant decreases in vertigo severity and monthly attack frequency 5.

Comparison to Other Treatments

• Vestibular rehabilitation (VR) has been proposed as an effective method for managing residual dizziness after successful repositioning maneuvers in patients with BPPV, with or without betahistine 6.
• A randomized controlled trial is ongoing to investigate the efficacy of VR compared to betahistine or VR plus betahistine treatment in mitigating residual dizziness and improving balance function in patients with BPPV 6.