Medications for Acute Peripheral Vertigo
For acute peripheral vertigo, use meclizine 25–100 mg daily as-needed for short-term symptom control (≤3–5 days), reserving benzodiazepines for severe disabling attacks and prochlorperazine specifically for severe nausea/vomiting—but never use any vestibular suppressant as primary treatment for BPPV, which requires canalith repositioning maneuvers. 1
First-Line Medication: Meclizine
Meclizine is the most commonly used antihistamine for peripheral vertigo and should be prescribed as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation. 1
- Dosing: 25–100 mg daily in divided doses, depending on clinical response. 1, 2
- Mechanism: Suppresses the central emetic center through anticholinergic and antihistaminic actions. 1
- Duration: Limit use to 3–5 days maximum during acute attacks; prolonged use (>10–15 days/month) can cause rebound vertigo and impede central compensation. 1
When to Use Meclizine
- Vestibular neuritis: Short-term symptom control during the acute phase. 1
- Ménière's disease: Only during acute attacks, not as continuous therapy. 1, 3
- Severe autonomic symptoms: For patients with disabling nausea who cannot tolerate repositioning maneuvers. 3
When NOT to Use Meclizine
- BPPV: Meclizine is explicitly not recommended as primary treatment because it does not address the mechanical cause (displaced otoconia). Canalith repositioning maneuvers achieve 78.6–93.3% improvement versus only 30.8% with medication alone. 3
- During vestibular rehabilitation: Vestibular suppressants impede the compensation process essential for long-term recovery. 1, 4
Second-Line: Benzodiazepines (e.g., Diazepam, Clonazepam)
Benzodiazepines may be used for short-term management (≤3–5 days) of severe, disabling vertigo that prevents normal functioning, particularly when psychological anxiety is prominent. 1, 4
- Indications: Severe acute vestibular attacks (vestibular neuritis, Ménière's disease) where symptoms are incapacitating. 4
- Mechanism: Suppress vestibular nuclei activity and reduce anxiety secondary to vertigo. 1
- Contraindications:
Comparative Efficacy
- Diazepam 5 mg and meclizine 25 mg are equally effective for acute peripheral vertigo, with no significant difference in symptom improvement at 60 minutes (mean VAS improvement: 36 mm vs. 40 mm, respectively). 5
For Severe Nausea/Vomiting: Prochlorperazine
Prochlorperazine is the preferred antiemetic for severe nausea/vomiting associated with vertigo, but it is not recommended as primary treatment for vertigo itself. 1, 3
- Dosing: 5–10 mg orally or intramuscularly, maximum three doses per 24 hours. 1
- Mechanism: Potent dopaminergic antagonist acting on central and peripheral receptors. 1
- Advantages: More effective and better tolerated than metoclopramide, with higher bioavailability and less sedation. 1
- Cautions:
Medications to Avoid
Betahistine
- No significant benefit over placebo in reducing vertigo attack frequency in Ménière's disease (BEMED trial, 2020). 1
Metoclopramide
- Not recommended as primary treatment due to lower efficacy, reduced oral bioavailability in the presence of vomiting, and higher risk of extrapyramidal side effects compared to prochlorperazine. 1
Opioids and Butalbital
- Should never be used for acute episodic vertigo due to lack of proven benefit and significant safety concerns. 1
Critical Safety Warnings
Fall Risk
- Vestibular suppressants are an independent risk factor for falls, especially in elderly patients who already have elevated fall risk from vertigo. 1, 4
- Educate patients about postural hypotension and avoid polypharmacy when possible. 1
Anticholinergic Side Effects
- Meclizine can cause drowsiness, cognitive deficits, dry mouth, blurred vision, and urinary retention—particularly problematic in elderly patients. 3, 2
- Use with caution in patients with asthma, glaucoma, or prostate enlargement. 2
Interference with Compensation
- Long-term use of vestibular suppressants interferes with central vestibular compensation, delaying recovery. 1
- Withdraw medications as soon as possible—preferably after the first several days—and transition to vestibular rehabilitation therapy. 1, 4
Clinical Decision Algorithm
Step 1: Confirm Diagnosis
- BPPV (triggered, brief episodes): Perform Dix-Hallpike or supine head-roll test. Do not prescribe medications; perform Epley or Semont maneuver (≈80% success rate). 3
- Vestibular neuritis (prolonged vertigo >24 hours): Consider short-term meclizine or benzodiazepine (≤5 days). 1
- Ménière's disease (episodic vertigo + hearing loss + tinnitus): Use vestibular suppressants only during acute attacks; implement salt restriction (1500–2300 mg/day) and consider diuretics for maintenance. 1, 3
Step 2: Assess Severity
- Mild-to-moderate symptoms: Meclizine 25–100 mg PRN. 1
- Severe, disabling symptoms: Consider benzodiazepine (e.g., diazepam 5 mg) for ≤5 days. 4
- Severe nausea/vomiting: Add prochlorperazine 5–10 mg (max 3 doses/24 hours). 1
Step 3: Initiate Vestibular Rehabilitation
- Begin within the first week after acute symptoms subside. 1
- Discontinue all vestibular suppressants before starting rehabilitation to avoid impeding compensation. 1, 4
Step 4: Reassess at 1 Month
- Document symptom resolution or persistence. 1, 3
- If symptoms persist, evaluate for recurrence, additional canal involvement, co-existing disorders (vestibular migraine, persistent postural-perceptual dizziness), or central causes (stroke, demyelinating disease). 3
Common Pitfalls to Avoid
- Prescribing meclizine for BPPV: This is ineffective and delays definitive treatment with repositioning maneuvers. 3
- Scheduled dosing of meclizine: Use PRN to minimize interference with vestibular compensation. 1
- Prolonged vestibular suppressant use: Limit to 3–5 days to avoid rebound vertigo and delayed recovery. 1
- Using vestibular suppressants during rehabilitation: This impedes the compensation process. 1, 4
- Ignoring fall risk in elderly patients: Vestibular suppressants significantly increase fall risk; consider deprescribing other contributing medications. 1, 4