Treatment · Introduction
Pharmacological management of vertigo
Two jobs, one rule. Drugs in vertigo either suppress the acute storm or treat the underlying disease — and the suppressants, however useful, must be stopped before they get in the way of recovery.
Two kinds of drug
Medicines for vertigo fall into two groups. The first calms the symptoms — the spinning, nausea and vomiting — during a bad attack. The second treats the actual cause, such as Ménière’s disease or migraine. The symptom-calming drugs are only meant for a few days; used for too long they actually slow recovery down.
The first group is the vestibular suppressants — antihistamines, anticholinergics, benzodiazepines and dopamine antagonists — which dampen vestibular signalling for short-term comfort but do nothing for the cause.4 The second is disease-targeted therapy aimed at specific mechanisms: betahistine and diuretics for hydrops, corticosteroids for neuritis, migraine prophylaxis, and SSRIs for PPPD.1
The therapeutic skill is matching the drug to the job and to the clock. Suppressants buy comfort in the acute crisis; targeted agents change the disease course. Both sit inside a framework whose foundations are non-pharmacological — repositioning manoeuvres, vestibular rehabilitation, and behavioural strategies — and the commonest prescribing error is to over-rely on suppressants and under-use those.1,2
The one rule worth memorising
Vestibular suppressants relieve symptoms by damping vestibular input — but that same damping blunts vestibular compensation, the neuroplastic recalibration that actually restores balance. So they are for the first 3–5 days of an acute episode and no longer; then they come off and rehabilitation begins.3
How this chapter is organised
- Vestibular suppressants — antihistamines, anticholinergics, benzodiazepines and dopamine antagonists, with their receptor targets and the 3–5 day rule.
- Disease-targeted therapy — Ménière’s disease, vestibular neuritis, vestibular migraine and PPPD.
- Central vertigo — treating the underlying stroke, MS or tumour, with suppressants in a supporting role only.
- Special populations & cautions — duration of use, the elderly, and pregnancy.
- Emerging therapies — neuromodulation, NMDA and cannabinoid modulation, and inner-ear drug delivery.
- Drug formulary — the full, filterable reference of every agent in the chapter.
Key points
- Vertigo drugs are either symptomatic suppressants or disease-targeted therapy.
- Suppressants give short-term relief but do not treat the cause.
- Limit suppressants to 3–5 days — longer use delays vestibular compensation.
- Targeted therapy (betahistine, steroids, migraine prophylaxis, SSRIs) addresses specific mechanisms.
- Pharmacology supports, but does not replace, repositioning manoeuvres and rehabilitation.