Benign Positional Vertigo in Emergency Medicine Medication

  • Author: Andrew K Chang, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Apr 27, 2011
 

Medication Summary

Medical treatment for benign positional vertigo (BPV) is generally ineffective but may be used to lessen the symptoms.[4] The natural history of BPV is to resolve with time as the otoliths eventually dissolve while in the semicircular canals.

The use of vestibular suppressants is based on the sensory conflict theory, in which sensory input is compared from different systems, and if a conflict exists, then nausea and vomiting result. Over time, habituation occurs. Several main neurotransmitters mediate these functions: GABA, acetylcholine, and histamine/serotonin.

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Antihistaminic antiemetics

Class Summary

The antihistaminic antiemetics block the emetic response. For patients with severe vertigo or vomiting, intravenous promethazine (Phenergan) is the drug of choice; prochlorperazine (Compazine) is not very useful in this context. Meclizine is given orally and does not work fast enough to be effective acutely. Most antiemetics have anticholinergic activity as well.

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Promethazine (Phenergan, Anergan, Prorex)

 

Antidopaminergic agent used to treat emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to brainstem reticular system. Also has cross reactivity with the cholinergic receptors.

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Meclizine (Antivert, Antrizine, Dramamine)

 

Decreases excitability of middle ear labyrinth and blocks conduction in middle ear vestibular-cerebellar pathways. These effects are associated with relief of nausea and vomiting.

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Benzodiazepines

Class Summary

These agents block the GABA receptors and serve as the "brakes" to the system. Although they can be used acutely in the ED, they are not recommended for long-term use because they interfere with the process of vestibular rehabilitation.

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Lorazepam (Ativan)

 

Sedative hypnotic in benzodiazepine class that has short time to onset and relatively long half-life. Depresses all levels of CNS, including limbic and reticular formation, probably through increased action of GABA, a major inhibitory neurotransmitter.

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Anticholinergics

Class Summary

These agents block the conflict signal sites.

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Scopolamine (Isopto, Scopace Tablet)

 

Blocks action of acetylcholine at parasympathetic sites in the smooth muscle, secretory glands, and CNS. Antagonizes histamine and serotonin action.

Transdermal scopolamine may be most effective agent for motion sickness. Use in the treatment of BPV is limited by slow onset of action.

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Dimenhydrinate (Dimetabs, Dramamine)

 

Mixture of 1:1 salt consisting of 8-chlorotheophylline and diphenhydramine. Believed to be useful, particularly in treatment of vertigo. Diminishes vestibular stimulation and depresses labyrinthine function through central anticholinergic effects. However, prolonged treatment may decrease rate of recovery of vestibular injuries.

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Sympathomimetic

Class Summary

These agents are useful in reversing soporific effects of vestibular sedatives.

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Methylphenidate (Ritalin)

 

Piperidine derivative most commonly prescribed; efficacy has been demonstrated in randomized, double-blind, dose-response, and placebo-controlled trials. Stimulates cerebral cortex and subcortical structures.

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Contributor Information and Disclosures
Author

Andrew K Chang, MD  Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward Bessman, MD  Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

J Stephen Huff, MD  Associate Professor, Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia Health Sciences Center

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD 

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. Jun 1991;66(6):596-601. [Medline].

  2. [Guideline] Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Nov 2008;139(5 Suppl 4):S47-81. [Medline]. [Full Text].

  3. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. Nov 18 1999;341(21):1590-6. [Medline].

  4. [Guideline] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. May 27 2008;70(22):2067-74. [Medline]. [Full Text].

  5. Epley JM. Particle repositioning for benign paroxysmal positional vertigo. Otolaryngol Clin North Am. Apr 1996;29(2):323-31. [Medline].

  6. Kim AS, Fullerton HJ, Johnston SC. Risk of vascular events in emergency department patients discharged home with diagnosis of dizziness or vertigo. Ann Emerg Med. Jan 2011;57(1):34-41. [Medline].

  7. Baloh RW. Dizziness and vertigo. In: Samuels MA, Feske S. Office Practice of Neurology. London: Churchill Livingstone; 1996:83-91.

  8. Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol. Aug 1980;106(8):484-5. [Medline].

  9. Chang AK, Schoeman G, Hill M. A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo. Acad Emerg Med. Sep 2004;11(9):918-24. [Medline].

  10. Froehling DA, Bowen JM, Mohr DN, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc. Jul 2000;75(7):695-700. [Medline].

  11. Lempert T, Gresty MA, Bronstein AM. Benign positional vertigo: recognition and treatment. BMJ. Aug 19 1995;311(7003):489-91. [Medline].

  12. Marill KA, Walsh MJ, Nelson BK. Intravenous Lorazepam versus dimenhydrinate for treatment of vertigo in the emergency department: a randomized clinical trial. Ann Emerg Med. Oct 2000;36(4):310-9. [Medline].

  13. Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. Apr 1996;25(2):121-5. [Medline].

  14. Troost BT, Patton JM. Exercise therapy for positional vertigo. Neurology. Aug 1992;42(8):1441-4. [Medline].

 
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Anatomy of the semicircular canals.
Epley maneuver. Move the patient back in the gurney such that when he lies down, his or her head will hang over the edge of the gurney. Emphasize to the patient to keep his or her eyes open during each position so that nystagmus can be observed. Lower the guardrails of the gurney on the opposite side from which the patient's head is turned.
Epley maneuver. Turn the patient's head 45° to the side that had the most prominent symptoms during the Hallpike test. In this example, the patient's head is turned 45° to the left. With both hands holding the patient's head, gently lay the patient down in the supine position with the head hanging over the edge of the bed. Note: Each maneuver does not need to be performed rapidly. The Epley maneuver is positional, not positioning.
Epley maneuver. The patient's head should be at 45° and hanging off the edge of the bed. Observe the patient's eyes and look for torsional nystagmus. Keep the patient in this position for at least 30 seconds or until the nystagmus or symptoms resolve.
Epley maneuver. Because the patient's head will be turned 90° in the other direction, the physician needs to move to the head of the gurney and regrip the patient's head so that the fingers are pointing toward the patient's feet.
Epley maneuver. Turn the patient's head 90° in the opposite direction (in this case, the patient's head is now facing to the right). Again, observe for nystagmus and hold this position for at least 30 seconds or until nystagmus or symptoms resolve.
Epley maneuver. Close-up view of step shown in Media file 6.
Epley maneuver. Ask the patient to turn onto his or her shoulder.
Epley maneuver. Guide the patient's head down so that he or she is looking at the ground. Again, wait for at least 30 seconds.
Epley maneuver. Close-up of view shown in Media file 9.
Epley maneuver. The patient's head needs to be regripped again. Then, the patient needs to sit up with the legs hanging over the side of the gurney (which is why the guardrails need to be lowered before the start of the procedure).
Epley maneuver. The patient is now sitting upright.
Epley maneuver. Move the patient's head slightly forward. This completes the Epley maneuver. The maneuver may be performed multiple times.
Hallpike test. In this example, the right posterior semicircular canal is being tested. Note that the head extends over the edge of the gurney. The thumb can be used to help keep the eyelids open since noting the direction of the nystagmus is important.
Epley maneuver. In this example, the left posterior semicircular canal is being treated. In this clip, the maneuvers are performed quickly. In a real patient, each position should be held for at least 30 seconds or until resolution of the nystagmus and vertigo.
Semont maneuver. Generally reserved for the cupulolithiasis form of benign positional vertigo, in which the otoliths are attached to the cupula of the semicircular canal. This maneuver has to be performed rapidly to be effective, and it is not recommended in elderly persons. In this example, the right posterior semicircular canal is being treated.
Bar-b-que maneuver. This maneuver is used to treat horizontal canal benign positional vertigo. In this example, the right horizontal canal is being treated. Each position should be held at least 20-30 seconds.
 
 
 
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