Vertigo Management

Aka: Vertigo Management

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II. General

  1. Evaluate and treat specific Vertigo Causes
  2. Medications are indicated for symptomatic acute Vertigo
    1. Medications decrease symptoms, but do NOT treat the underlying pathology
  3. Avoid use of symptom control medications >3 days
    1. Stopping medications allows brain to equilibrate to Vertigo
    2. Continued use of medications may prolong Vertigo episode
  4. Early ambulation improves rate of recovery
  5. Rehabilitation Exercises
    1. Epley Maneuver
      1. Indicated for Benign Paroxysmal Positional Vertigo (BPPV)
    2. Prescribed program of head movements and activity
      1. Improves symptom adaptation and balance
      2. Yardley (2004) Ann Intern Med 141:598-605 [PubMed]

III. Management: Symptomatic Therapy - Outpatient

  1. Precautions
    1. Limit to 3 days only (to allow central compensation to proceed)
  2. Over the counter medications (Category B in pregnancy)
    1. Antihistamines risk Anticholinergic side effects (sedation, Urinary Retention, Altered Mental Status, Blurred Vision, falls in elderly)
    2. Meclizine (Antivert)
      1. Age >12 years: 25 mg orally every 6 hours as needed
      2. Precaution: Sedating
    3. Dimenhydrinate (Dramamine)
      1. Preferred as better Anti-emetic effect and less sedation than Meclizine
      2. Adults: 50-100 mg orally every 4-6 hours (max: 400 mg/day)
      3. Age 2-5: 12.5-25 mg orally every 6-8 hours (max: 75 mg/day)
      4. Age 6-12: 25-50 mg orally every 6-8 hours (max: 150 mg/day)
  3. Antiemetics
    1. Ondansetron ODT (Zofran ODT) 4 mg IV/IM/PO every 6 hours as needed
    2. Metoclopramide (Reglan) 10 mg orally every 6 hours as needed
  4. Benzodiazepines for severe symptoms (adult dosing)
    1. Avoid Benzodiazepines in most cases of outpatient Vertigo Management
      1. Lower efficacy when compared with Antihistamines
      2. Higher risk of respiratory depression, falls in elderly and dependency/misuse
    2. Diazepam (Valium) 5-10 mg orally every 6 hours
    3. Lorazepam (Ativan) 0.5-2 mg orally every 6 hours

IV. Management: Symptomatic Therapy - Emergency Department

  1. First Line agents with dual Anti-emetic and anti-Vertigo activity
    1. Promethazine (Phenergan)
      1. Dose: 6.25 to 12.5 mg slow IV push (or 12.25 to 25 mg IM/PO/PR) as needed every 6 hours
      2. Consider Ondansetron instead in the elderly due to Anticholinergic effects
    2. Dimenhydrinate (Dramamine)
      1. Dose: 50 mg IV every 4 to 6 hours prn
      2. IV preparation has limited availability (oral tablets may be used if Vomiting is controlled)
  2. Bicarbonate and Diphenhydramine protocol (dosing based on Taiwan protocol, needs modification for use in U.S.)
    1. Diphenhydramine 30 mg in 100 ml Normal Saline IV
    2. Sodium Bicarbonate 66.4 mEq (1.5 ampules bicarbonate) slowly pushed for 2 minutes
    3. Chi (2025) JAMA Netw Open 8(11):e2541472 +PMID: 41196596 [PubMed]
  3. Other Anti-emetics
    1. Prochlorperazine (Compazine) 5-10 mg IV/IM every 3-4 hours as needed
    2. Ondansetron (Zofran) 4 mg IV/IM/PO every 6 hours as needed
  4. Severe Vertigo symptoms (esp. if preparing for MRI tolerance)
    1. Lorazepam (Ativan) 0.5 to 2 mg IV/IM/PO every 6 hours as needed
    2. Diazepam (Valium) 2 mg IV or 5 mg IM/PO every 6 hours as needed

V. References

  1. Ondrejka (2014) Crit Dec Emerg Med 28(10): 11-7
  2. Marill (2000) Ann Emerg Med 36:310-9 [PubMed]
  3. Swartz (2005) Am Fam Physician 71:1115-30 [PubMed]

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