Acute pharmacology

In acute vertigo most patients need at most two drugs: an antiemetic to stop vomiting, and a short-acting vestibular suppressant for severe symptoms. Everything else depends on the diagnosis.

The biggest pharmacological mistake in vertigo care is the long-term meclizine prescription. Suppressants relieve the symptom but blunt the central adaptation that drives recovery. Use them sparingly, stop them early.

The corticosteroid evidence in vestibular neuritis is mixed. Strupp's 2004 NEJM trial showed methylprednisolone hastened recovery of caloric function; valacyclovir alone did not.1 A Cochrane review concluded that overall benefit on patient-reported outcomes is modest at best.2 Pragmatically: short taper if presenting within 72 hours and contraindications acceptable; do not insist.

Vestibular rehabilitation is the single highest-evidence treatment for peripheral vestibular hypofunction.3 It is started in the outpatient setting but referred from the ED — within 72 hours improves outcome.

For confirmed ischaemic stroke / TIA the AHA/ASA stroke pathway governs: non-contrast CT first; aspirin or thrombolysis per the time window and contraindication screen.4 Posterior-circulation strokes presenting with vertigo are systematically under-treated because they reach the door later —HINTS is the gate that gets them in.

Wernicke is the empirical-treatment exception. Suspect it in any acutely confused, ataxic patient with a relevant risk profile (alcohol, malnutrition, hyperemesis, post-bariatric), give IV thiamine immediately, and never give glucose first.