Benign Positional Vertigo in Emergency Medicine Medication

Updated: Mar 21, 2018
  • Author: Andrew K Chang, MD, MS; Chief Editor: Liudvikas Jagminas, MD, FACEP  more...
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Medication Summary

Medical treatment for benign positional vertigo (BPV) is generally ineffective but may be used to lessen the symptoms. [5] The natural history of BPV is to resolve with time as most 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 vertigo, nausea, and vomiting result. Over time, habituation occurs. Several main neurotransmitters mediate these functions: GABA, acetylcholine, and histamine/serotonin.


Antiemetic Agents

Class Summary

The antihistaminic antiemetics block the emetic response. For patients with severe vertigo or vomiting, intravenous promethazine (Phenergan) used to be the drug of choice; however, this medication recently received a Black Box Warning from the FDA and is now only recommended to be given intramuscularly. Prochlorperazine (Compazine) is an alternative antiemetic. Meclizine is given orally and does not work fast enough to be effective acutely. Most antiemetics have anticholinergic activity as well.

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.

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.

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.

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.


Antiemetics, Selective 5-HT3 Antagonist

Class Summary

These agents are an option for treating emesis associated with BPV. They may be administered IV, IM, or orally, including an orally disintegrating tablet and oral soluble film.

Ondansetron (Zofran, Zofran ODT, Zuplenz)

Ondansetron selective 5-HT3 receptor antagonist; binds to 5-HT3 receptors both in periphery and in CNS, with primary effects in GI tract. It has no effect on dopamine receptors and therefore does not cause extrapyramidal symptoms.



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.

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.