Vertigo medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

Central Disorders

• Treat underlying disease
• Vertebrobasilar ischemia

1. Vertigo usually resolves on its own
2. Risk factor modification to decrease recurrence
3. Revascularization or anticoagulation

• Migraine: Adequate treatment of headache improves vertigo in 90%.
• Multiple sclerosis (MS): Therapy for MS alleviates vertiginous symptoms as well
• Drugs: discontinue offending agents

Peripheral Disorders

• General management
• Physical therapy

1. Beneficial in patients with permanent peripheral vestibular dysfunction
2. Unknown benefit in patients with central disorders
3. Vestibular rehabilitation

• Activity enables CNS adaptation to loss of vestibular input
• Visual compensation during head motion
• Balance shown to improve in randomized controlled trials of vestibular exercises
• Unclear if long-term benefits or if decreased fall risk
• Avoidance of inactivity
• Avoid deconditioning and loss of postural reflexes

Acute Pharmacotherapies

Peripheral Disorders

• Specific management

1. BPPV
2. Epley maneuver --> in a randomized controlled trial, symptoms resolved in 50% vs. 19% sham therapy by mean 10 days
3. Meclizine (12.5-50 mg every 6 hours as often as necessary) or promethazine (25 mg every 6 hours as often as necessary) for severe symptoms
4. Meniere’s disease: low-salt diet and diuretics to reduce endolymph production

• Anticonvulsants such as topiramate or valproic acid for vestibular migraines

• General management

Pharmacologic Therapy

• For acute episodes:

1. Avoid long-term therapy if symptoms last > few days (will reduce CNS adaptation)
2. Anticholinergics
3. Scopolamine: Side effect urinary retention, dry mouth
4. Antihistamines such as betahistine, dimenhydrinate, or meclozine, which may have antiemetic properties
5. Meclizine, dimenhydrinate, diphenhydramine (anti-Ach effects)
6. Meclizine is drug of choice in pregnancy. Side effect: sedation
7. Phenothiazines
8. Prochlorperazine, promethazine (anti-Ach effects): More sedating, but also have antiemetic effects. Risk: extrapyramidal side effect (second-line)
9. Benzodiazepines
10. Diazepam, lorazepam, clonazepam (GABA-ergic effects): For patients with contraindications to anti-Ach prescription (benign prostatic hypertrophy)