Anti-vertigo drugs: relieve symptoms, but do not miss the cause
Vertigo is an illusion of movement, usually spinning. Medicines can reduce severe acute nausea and vestibular symptoms, but they do not replace diagnosis, repositioning manoeuvres, vestibular rehabilitation or treatment of a central cause. Long-term vestibular suppression can delay central compensation and may worsen falls.
Red flags: do not simply prescribe an antiemetic
New focal weakness/numbness, dysarthria, diplopia, severe gait ataxia, sudden severe headache, new central-pattern nystagmus, chest pain/syncope, acute deafness, persistent inability to walk, trauma or severe dehydration requires urgent assessment for stroke or another serious cause.
1. Think syndrome first
| Pattern | Likely approach | Role of medicines |
|---|---|---|
| Brief positional attacks (BPPV) | Positional examination and canalith repositioning manoeuvre. | Medicines rarely solve BPPV; avoid prolonged vestibular suppressants. |
| Acute vestibular syndrome (neuritis/labyrinthitis after central cause excluded) | Hydration, short-term symptom control, early mobilization/vestibular rehabilitation. | Short course only for severe vertigo/nausea. |
| Ménière-type episodes | ENT review, audiology and disease-specific plan. | Betahistine is used in some settings; evidence and local availability vary. |
| Central vertigo/stroke concern | Urgent neurologic evaluation. | Symptom relief must never delay imaging/referral where indicated. |
2. Medicines and indicative adult doses
| Medicine | Usual role / common adult regimen | Key cautions |
|---|---|---|
| Prochlorperazine | Vestibular nausea/acute vertigo; common oral regimens are 5 mg three times daily or 5–10 mg as directed by local product guidance. | Drowsiness, dystonia/EPS, hypotension, QT risk; avoid/seek advice in Parkinsonism and with other dopamine blockers. |
| Cinnarizine | Short-term vestibular suppression; commonly 15–30 mg up to three times daily depending on local formulation. | Sedation, anticholinergic effects and parkinsonism risk; avoid driving and avoid prolonged use. |
| Meclizine/cyclizine/promethazine | Antihistamine options for nausea and motion-related vestibular symptoms; product-specific regimens vary. | Anticholinergic burden, blurred vision, urinary retention, confusion and falls—especially in older adults. |
| Betahistine | Used in some protocols for Ménière-related vertigo; a common regimen is 16 mg three times daily initially, then maintenance in divided doses. | Not a treatment for generic imbalance. Use caution in asthma and peptic-ulcer disease; efficacy varies. |
| Diazepam | Occasional specialist-directed rescue vestibular suppressant only. | Dependence, falls and respiratory depression; avoid routine/long-term use and avoid with alcohol/opioids. |
Duration matters: use vestibular suppressants only for the shortest severe acute period, then reduce them and encourage mobilization/rehabilitation as clinically appropriate. Continuing a sedating medicine because the patient still feels “off balance” may increase falls without treating the cause.
3. Safe assessment and follow-up
- Confirm true vertigo versus presyncope, disequilibrium, anxiety or medication-related dizziness.
- Check onset, trigger, hearing loss/tinnitus, headache, neurologic symptoms, infection, trauma, cardiovascular symptoms and medicines.
- Assess gait, eye movements/nystagmus, hydration, blood pressure including postural measurements when relevant, glucose and focused neurologic signs.
- Review sedation, falls, anticholinergic burden, QT-risk drugs and ability to drive/work safely.
- Give a time-limited plan and explicit safety net; arrange repositioning/rehabilitation or referral where indicated.
OSCE point
Say: “I will first exclude stroke or another central cause. If this is a peripheral acute vestibular syndrome, I will use a short course of an antiemetic/vestibular suppressant only when symptoms are severe, then stop it early and support vestibular rehabilitation.”
