This review discusses the physiology and pharmacological treatment of
vertigo and related disorders. Classes of medications useful in the treatment of
vertigo include
anticholinergics,
antihistamines,
benzodiazepines,
calcium channel antagonists and
dopamine receptor antagonists. These medications often have multiple actions. They may modify the intensity of symptoms (e.g. vestibular suppressants) or they may affect the underlying disease process (e.g.
calcium channel antagonists in the case of vestibular
migraine). Most of these agents, particularly those that are sedating, also have a potential to modulate the rate of compensation for vestibular damage. This consideration has become more relevant in recent years, as vestibular rehabilitation
physical therapy is now often recommended in an attempt to promote compensation. Accordingly,
therapy of
vertigo is optimised when the prescriber has detailed knowledge of the pharmacology of medications being administered as well as the precise actions being sought. There are four broad causes of
vertigo, for which specific regimens of
drug therapy can be tailored. Otological
vertigo includes disorders of the inner ear such as
Ménière's disease,
vestibular neuritis,
benign paroxysmal positional vertigo (BPPV) and bilateral vestibular
paresis. In both
Ménière's disease and
vestibular neuritis, vestibular suppressants such as
anticholinergics and
benzodiazepines are used. In
Ménière's disease,
salt restriction and
diuretics are used in an attempt to prevent flare-ups. In
vestibular neuritis, only brief use of vestibular suppressants is now recommended.
Drug treatments are not presently recommended for BPPV and bilateral vestibular
paresis, but
physical therapy treatment can be very useful in both. Central
vertigo includes entities such as
vertigo associated with
migraine and certain
strokes. Prophylactic agents (L-channel
calcium channel antagonists,
tricyclic antidepressants, beta-blockers) are the mainstay of treatment for
migraine-associated
vertigo. In individuals with
stroke or other structural lesions of the brainstem or cerebellum, an eclectic approach incorporating trials of vestibular suppressants and
physical therapy is recommended. Psychogenic
vertigo occurs in association with disorders such as
panic disorder,
anxiety disorder and
agoraphobia.
Benzodiazepines are the most useful agents here. Undetermined and ill-defined causes of
vertigo make up a large remainder of diagnoses. An empirical approach to these patients incorporating trials of medications of general utility, such as
benzodiazepines, as well as trials of medication withdrawal when appropriate,
physical therapy and psychiatric consultation is suggested.