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, diphenhydramine, or meclizine, which may have antiemetic properties (anti-Ach effects)
5. Meclizine is drug of choice in pregnancy. Side effect: sedation
6. Phenothiazines
7. Prochlorperazine, promethazine (anti-Ach effects): More sedating, but also have antiemetic effects. Risk: extrapyramidal side effect (second-line)
8. Benzodiazepines
9. Diazepam, lorazepam, clonazepam (GABA-ergic effects): For patients with contraindications to anti-Ach prescription (benign prostatic hypertrophy)
10. Calcium channel antagonists, specifically Verapamil and Nimodipine
11. Beta blockers such as metoprolol for vestibular migraine
12. GABA modulators, specifically gabapentin and baclofen
13. Neurotransmitter reuptake inhibitors such as SSRI's, SNRI's and Tricyclics
14. Diuretics for Meniere's Disease