Treatment of Acute Vertigo
September 30, 2022 3 minutes read
By Louise M. Klebanoff, MD
Assistant Professor of Clinical Neurology, Weill Cornell Medical College
SYNOPSIS: Treating acute vertigo with an antihistamine was more effective than benzodiazepines for acute symptoms. However, there was no difference between the two medications in terms of resolution within one week or one month.
SOURCE: Hunter BR, Wang AZ, Bucca AW, et al. Efficacy of benzodiazepines or antihistamines for patients with acute vertigo: A systematic review and meta-analysis. JAMA Neurol 2022; Jul 18. doi:10.1001/jamaneurol.2022.1858. [Online ahead of print].
Vertigo is a common and frequently disabling sensation of movement that can affect up to 20% of adults, with an increasing incidence with age and a higher prevalence among women. The etiology of acute vertigo includes benign paroxysmal positional vertigo (BPPV), vestibular neuronitis, Ménière’s disease, vestibular migraine, and stroke, among others. Treatment can be tailored to the specific cause of vertigo, especially with repositioning techniques used for BPPV.
However, persistent complaints of dizziness often require medication. Antihistamines and benzodiazepines are prescribed often as vestibular suppressants; however, the efficacy of these medications remains unclear. Hunter et al performed a systematic review and meta-analysis assessing the relative efficacy of benzodiazepines and antihistamines when compared to each other, other active treatments, placebo, or no intervention in the treatment of acute vertigo from any underlying cause.
The authors reviewed randomized or quasi-randomized trials that compared any antihistamine or benzodiazepine with a comparator, placebo, or no intervention in patients with acute vertigo (durations of two weeks or shorter) of any etiology. The predefined primary outcome was change in 10- or 100-point vertigo or dizziness visual analogue scale (VAS) score at two hours after treatment. Secondary outcomes included change in nausea at two hours, need for rescue medication or intervention at two hours, resolution of vertigo at one week, resolution at one month, improvement at one week, improvement at one month, and nystagmography results. A good or satisfactory improvement was defined as patient-rated improvement with at least a 50% reduction in symptom severity on any numeric scale.
There were 17 studies with 1,586 participants included in the quantitative results; most patients were diagnosed with “generalized or nonspecific peripheral vertigo.” These antihistamines were used: betahistine (two studies), cinnarizine (four studies), dimenhydrinate (seven studies), flunarizine (two studies), meclizine (one study), and promethazine (two studies). Antihistamines were compared to benzodiazepines (three studies), placebo or no treatment (seven studies), and other active controls (six studies). The only benzodiazepines studied were lorazepam and diazepam, which were compared with antihistamines (three studies) or placebo (one study). Four studies included patients with BPPV and those authors compared Epley repositioning maneuvers alone to Epley maneuvers in combination with antihistamines.
For the primary outcomes, seven studies totaling 802 patients were included in the meta-analysis. All studies compared antihistamines to other treatments. Antihistamines were associated with a 16.1-point greater decrease in vertigo (95% CI, 7.2-25.0) than benzodiazepines based on a VAS at two hours after administration of medication. There were no differences seen in the secondary outcome measurements. There was no statistically significant difference in improvement on the vertigo VAS at one week following treatment, no increase in the likelihood of complete resolution of symptoms at one week, and no differences in improvement or complete resolution of symptoms at one month. Of the six trials that included nystagmometry measurements, one suggested that dimenhydrinate was superior to diazepam and four showed greater improvement in nystagmus in patients treated with antihistamines compared with placebo. Hunter et al concluded there is moderately strong evidence suggesting single-dose antihistamines result in better improvement in vertigo at two hours than single-dose benzodiazepines.
COMMENTARY
Treating vertigo remains challenging. Vertigo has many etiologies; the benefit of any specific treatment may vary depending on the specific diagnosis. Patients often struggle to describe their symptoms, physicians do not always agree on terminology, and there are no diagnostic studies that provide definitive diagnoses. Although this meta-analysis provides support for the use of antihistamines over benzodiazepines to manage acute vertigo, the authors did not provide recommendations based on the etiology of the complaint or for patients with chronic vertigo.
Going forward, additional randomized, controlled studies comparing treatments of vertigo are needed. It would be best if there were well-defined diagnostic criteria so different causes of vertigo can be assessed independently.
Treating acute vertigo with an antihistamine was more effective than benzodiazepines for acute symptoms. However, there was no difference between the two medications in terms of resolution within one week or one month.
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