Reference
Drug formulary
Every agent in the chapter in one place. Filter by drug class or by treatment horizon — acute/symptomatic versus maintenance/targeted — to compare indication, dose, mechanism, cautions and the strength of the evidence.
Drug formulary
27 of 27 agents- MeclizineAntihistamineSymptomatic only
- For
- Acute peripheral vertigo, motion sickness
- Dose
- 25–50 mg PO 2–3×/day
- Mechanism
- H1 antagonist with weak anticholinergic action; dampens vestibular-nucleus signalling
- Cautions
- Sedation (less than others), dry mouth; safer choice in pregnancy (FDA category B)
- DimenhydrinateAntihistamineSymptomatic only
- For
- Acute vertigo with nausea, motion sickness
- Dose
- 50–100 mg PO every 4–6 h
- Mechanism
- Diphenhydramine + chlorotheophylline salt; H1/anticholinergic, fast onset
- Cautions
- Marked sedation; limit in older adults and tasks needing alertness
- PromethazineAntihistamineSymptomatic only
- For
- Acute vertigo with intractable nausea/vomiting (ED)
- Dose
- 12.5–25 mg PO/IM
- Mechanism
- Phenothiazine H1 antagonist with potent antiemetic and sedative effect
- Cautions
- Deep sedation, extrapyramidal symptoms
- DiphenhydramineAntihistamineSymptomatic only
- For
- Acute vertigo / nausea (selected)
- Dose
- 25–50 mg PO/IM
- Mechanism
- First-generation ethanolamine H1 antagonist
- Cautions
- High anticholinergic load and sedation; avoid in older adults, urinary retention, cognitive impairment
- Scopolamine (hyoscine)AnticholinergicModerate
- For
- Prophylaxis of motion sickness
- Dose
- 1.5 mg transdermal patch / 72 h behind the ear
- Mechanism
- Blocks M1 muscarinic receptors in vestibular nuclei, reticular formation and CTZ
- Cautions
- Confusion, delirium, dry mouth, blurred vision, urinary retention; avoid in elderly, glaucoma, BPH
- DiazepamBenzodiazepineSymptomatic only
- For
- Severe acute vertigo (e.g. neuritis, Ménière's attack)
- Dose
- 2–10 mg PO twice daily (short course)
- Mechanism
- GABA-A potentiation → suppresses vestibular-nucleus firing; rapid onset, long half-life
- Cautions
- Sedation, falls, dependence; delays central compensation — limit to 3–5 days
- LorazepamBenzodiazepineSymptomatic only
- For
- Acute vertigo, intermediate duration
- Dose
- 0.5–2 mg PO twice daily (short course)
- Mechanism
- GABA-A potentiation; shorter half-life than diazepam
- Cautions
- Sedation, dependence; limit duration, avoid during vestibular rehabilitation
- ClonazepamBenzodiazepineLimited
- For
- Vestibular hypersensitivity, vestibular migraine, functional dizziness
- Dose
- 0.25–0.5 mg PO twice daily
- Mechanism
- GABA-A potentiation with anxiolytic effect; reduces visual dependence
- Cautions
- Sedation, tolerance, dependence; not for chronic maintenance
- ProchlorperazineDopamine antagonistSymptomatic only
- For
- Vertigo-induced nausea and vomiting
- Dose
- 5–10 mg PO/IM three times daily
- Mechanism
- Blocks D2 receptors in the chemoreceptor trigger zone
- Cautions
- Extrapyramidal symptoms (dystonia, parkinsonism); short-term use only
- MetoclopramideDopamine antagonistSymptomatic only
- For
- Vertigo-associated nausea/vomiting
- Dose
- 10 mg PO/IV three times daily
- Mechanism
- Central + peripheral D2 antagonist; prokinetic antiemetic
- Cautions
- Extrapyramidal symptoms, especially in children and with prolonged use
- BetahistineHistamine analogueModerate
- For
- Ménière's disease — prophylaxis of attacks
- Dose
- 16–48 mg/day in divided doses
- Mechanism
- Weak H1 agonist + potent H3 antagonist; improves inner-ear microcirculation and endolymph resorption
- Cautions
- Generally well tolerated; caution in active peptic ulcer, asthma. Audiological benefit inconsistent
- Hydrochlorothiazide + triamtereneDiureticLimited
- For
- Ménière's disease — adjunct with low-sodium diet
- Dose
- One tablet daily (with diet < 1.5 g sodium/day)
- Mechanism
- Reduces body fluid volume → theoretically lowers endolymphatic pressure
- Cautions
- Electrolyte imbalance, dehydration, hypotension; monitor renal function. Evidence largely observational
- AcetazolamideDiureticLimited
- For
- Ménière's disease (selected); some episodic ataxias
- Dose
- 250–500 mg/day
- Mechanism
- Carbonic anhydrase inhibitor; mild diuresis and metabolic acidosis
- Cautions
- Paraesthesiae, electrolyte disturbance; limited Ménière's evidence
- Prednisone / methylprednisolone (oral)CorticosteroidModerate
- For
- Vestibular neuritis — accelerate recovery
- Dose
- Prednisone 60 mg/day, tapered over 10–14 days; start < 72 h
- Mechanism
- Anti-inflammatory; reduces vestibular-nerve oedema and improves caloric recovery
- Cautions
- Hyperglycaemia, GI irritation, immunosuppression; functional benefit debated
- IV methylprednisoloneCorticosteroidEstablished
- For
- MS relapse causing central vertigo
- Dose
- 1 g/day IV for 3–5 days (± oral taper)
- Mechanism
- High-dose anti-inflammatory; stabilises blood–brain barrier, shortens relapse
- Cautions
- Hyperglycaemia, mood change, infection risk; does not alter long-term MS course
- Intratympanic steroidIntratympanicModerate
- For
- Refractory Ménière's disease (hearing-sparing)
- Dose
- Dexamethasone / methylprednisolone via round window
- Mechanism
- Local anti-inflammatory; stabilises membrane permeability with minimal systemic effect
- Cautions
- Procedural; efficacy varies between individuals
- Intratympanic gentamicinIntratympanicModerate
- For
- Refractory disabling Ménière's vertigo
- Dose
- Titrated aminoglycoside via round window
- Mechanism
- Vestibulotoxic chemical ablation of vestibular hair cells (> 85% vertigo control)
- Cautions
- Risk of cochleotoxicity / hearing loss and persistent imbalance; specialist-administered
- SumatriptanMigraine — acuteLimited
- For
- Acute vestibular migraine attack
- Dose
- Per migraine protocol, taken early in the episode
- Mechanism
- 5-HT1B/1D agonist; reduces neurogenic inflammation and trigeminovascular signalling
- Cautions
- Cardiovascular contraindications; efficacy in VM more variable than in migraine with aura
- PropranololMigraine — prophylaxisModerate
- For
- Vestibular migraine prophylaxis
- Dose
- 40–160 mg/day
- Mechanism
- β-blocker; modulates adrenergic tone and cerebrovascular reactivity
- Cautions
- Bradycardia, fatigue, bronchospasm; avoid in asthma
- FlunarizineMigraine — prophylaxisModerate
- For
- Vestibular migraine prophylaxis (RCT-supported)
- Dose
- 10 mg/day
- Mechanism
- Calcium-channel blocker; stabilises vestibular neurons and reduces excitability
- Cautions
- Weight gain, sedation, depression, parkinsonism with long use
- AmitriptylineMigraine — prophylaxisLimited
- For
- VM with coexisting tension headache, insomnia or anxiety
- Dose
- 10–50 mg at bedtime
- Mechanism
- Tricyclic; inhibits serotonin/noradrenaline reuptake, modulating pain pathways
- Cautions
- Anticholinergic effects, sedation, QT prolongation
- TopiramateMigraine — prophylaxisModerate
- For
- Vestibular migraine prophylaxis, refractory cases
- Dose
- 25–100 mg/day
- Mechanism
- Modulates Na/Ca channels and enhances GABAergic inhibition
- Cautions
- Paraesthesiae, cognitive slowing, weight loss, teratogenicity
- SertralineSSRI / SNRIModerate
- For
- PPPD — first-line
- Dose
- 50–200 mg/day (start low, titrate)
- Mechanism
- Enhances serotonergic transmission in vestibular nuclei and parieto-insular cortex; reduces visual dependence
- Cautions
- Nausea, headache, sexual dysfunction; benefit takes 4–6 weeks
- ParoxetineSSRI / SNRIModerate
- For
- PPPD — RCT-supported (60–70% improvement)
- Dose
- 10–40 mg/day
- Mechanism
- SSRI; desensitises abnormal vestibulo-visual responses and motion-triggered anxiety
- Cautions
- Anticholinergic and discontinuation effects; titrate and taper
- VenlafaxineSSRI / SNRIModerate
- For
- PPPD — most-used SNRI
- Dose
- 75–150 mg/day
- Mechanism
- SNRI; serotonergic/noradrenergic modulation of central vestibular processing
- Cautions
- Hypertension at higher doses, nausea, discontinuation syndrome
- GabapentinOther / emergingLimited
- For
- Symptomatic nystagmus (e.g. in MS), some central vertigo
- Dose
- Titrated to effect
- Mechanism
- Modulates voltage-gated calcium channels; suppresses pathological nystagmus
- Cautions
- Sedation, dizziness, ataxia
- MemantineOther / emergingLimited
- For
- Pendular nystagmus; investigational for central imbalance
- Dose
- Titrated to effect
- Mechanism
- NMDA-receptor antagonist; modulates central vestibular plasticity
- Cautions
- Dizziness, headache; role in vertigo not yet established
For learning, not prescribing.Doses are illustrative teaching figures. Always verify the drug, dose, interactions and contraindications against the current formulary and the individual patient, and remember the chapter’s governing rule — symptomatic suppressants are for the first 3–5 days only.