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Central Nervous System Conditions: Vertigo and Dizziness

Yvonne M. Shevchuk, BSP, PharmD, FCSHP
Date Prepared: May 2010

Pathophysiology
Dizziness refers to a variety of sensations such as lightheadedness, fainting, spinning and giddiness.1 Vertigo is
defined as a sensation of motion where there is none or an exaggerated sense of motion in response to a given
bodily movement.2 It is the cardinal symptom of vestibular disease as a result of lesions or disturbances in the

inner ear, eighth cranial nerve or vestibular nuclei and their pathways in the brain stem and cerebellum. Vertigo is
usually accompanied by varying degrees of nausea and vomiting as well as pallor and perspiration. It may be
acute, chronic or recurrent. Specific conditions that produce vertigo are listed in Table 1.
Dizziness has a number of causes unrelated to ear conditions including cardiovascular conditions (e.g.,
arrhythmias, hypertension), metabolic or endocrine conditions (e.g., anemia, diabetes), psychiatric conditions and
neurological conditions (e.g., migraine, head injury).3
Table 1: Specific C onditions That Produce Vertigo
Type
Benign
paroxysmal
positioning
vertigo
(BPPV)

Treatmenta

Description
Most common type of vertigo
(20% of all cases)4

Physical manipulation of the head (e.g., Epley manoeuvre)6 much

Probable causes, such as viral

neuritis (see below), surgery,
infection, vasculitis and trauma,
identified in approximately 50%
of cases5

sequence of head position changes performed by a physician that

moves particles into the posterior semicircular canal toward the
utricle6

Presence of debris or small

crystals of calcium carbonate
(canaliths) in semicircular
canals4

more useful than drug therapy.4 Epley manoeuvre is a specific

Nausea treated with antiemetics 4

Vestibular rehabilitation (physical therapy program to improve
balance, eye-hand coordination and habituate the patient to
feelings of dizziness)5

Recurrent bouts of vertigo

(brief) resulting from changes in
head position5
Hearing loss and tinnitus not
usually present
Symptoms may disappear in a
few weeks but may recur
Menieres
disease

2nd most common cause of

vertigo of otologic origin4

Vestibular suppressants with or without antiemetics to treat

acute attacks4

Associated with distention of the

endolymphatic compartment of
the inner ear
Fluctuating hearing, roaring
tinnitus, aural fullness and
vertigo5

Prophylaxis
Dietary salt restriction (12 g/day), avoidance of caffeine and
smoking4

Vertigo has acute onset and

persists from 30 min to several
hours

Vestibular
neuritis

Self-limiting, preceded by a
nonspecific viral infection4 , 5
Due to viral infection of the
vestibular portion of the eighth
cranial nerve 4
Sudden onset vertigo, nausea,
ataxia and nystagmus4 , 5
Generally no hearing
impairment; if hearing

Diuretics, e.g., hydrochlorothiazide-triamterene (avoid loop

diuretics) often recommended but little evidence for benefit7
Betahistine is commonly used even though benefit is not
well established8
Avoid vestibular suppressants for prophylaxis as they
may impair vestibular compensation4

Reassurance and explanation; prognosis is excellent

Avoid movement as this exacerbates symptoms and use
vestibular suppressants and antiemetics for 23 days after
which symptoms have usually significantly decreased4
Use as few medications as possible and encourage as much
activity as tolerated so compensation is not delayed4 , 5

Methylprednisolone may have a role in vestibular recovery 9

BPPV may occur in up to 15% of patients with vestibular neuritis

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impairment present, is referred

to as labyrinthitis4
Symptoms constant for 23
days4

C entral
vertigo

Less than 5% of cases4

Treat underlying cause4

Often caused by vascular

disorders, e.g., stroke, transient
ischemic attack, migraine 4

a. Se e Table 3 for de scription of nonpre scription pharm acologic age nts.

Drug-induced causes of dizziness are listed in Table 2. Ototoxic drugs may also produce vertigo (see Ear
C onditions: Assessment of Patients with Hearing Loss, Ear Pain and Ear Drainage, Table 2).

Table 2: Medications That May C ause Dizziness

Class of Medication

Probable Mechanism

Example

Alpha 1-adrenergic antagonists

Orthostatic hypotension

Prazosin

Alcohol

Hypotension, osmotic effects

Wine, cough syrups

Aminoglycosides

Ototoxicity

Gentamicin

Antiepileptic drugs

Orthostatic hypotension

C arbamazepine

Antidepressants

Orthostatic hypotension

Desipramine

Anti-parkinsonian medication

Orthostatic hypotension

Levodopa

Antipsychotics

Orthostatic hypotension

Olanzapine

Beta-blockers

Hypotension or bradycardia

Atenolol

C alcium channel blockers

Hypotension, vasodilation

Verapamil

C lass la antiarrhythmics

Torsades de pointes

Procainamide

Digitalis glycosides

Hypotension

Digoxin

Diuretics

Volume contraction, vasodilation

Hydrochlorothiazide

Narcotics

C entral nervous system depression

Morphine, propoxyphene

Sulfonylureas

Hypoglycemia

Glyburide, tolbutamide

Vasodilators

Hypotension, vasodilation

Hydralazine

R e produce d with pe rm ission from Sloane PD e t al. Dizzine ss: state of the scie nce . Ann Intern Med 2001;134:823-32.

Goals of Therapy
Reduce or eliminate symptoms of vertigo4
Reduce or eliminate nausea and anxiety 4

Avoid compromising the process of vestibular compensation (allowing the brain to find a new sensory
equilibrium despite the vestibular lesion)4

Patient Assessment
Always seek drug-induced causes of vertigo and dizziness. All patients with vertigo should be assessed by a
physician. If the vertigo is accompanied by numbness, tingling or weakness in any part of the body, visual
disturbances, confusion or difficulty speaking, this is an emergency. C all 911 as the patient may be experiencing a
transient ischemic attack or stroke.

Nonpharmacologic Therapy
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Nonpharmacologic therapy depends on the cause of the vertigo; see Table 1.

Pharmacologic Therapy
Drug therapy for vertigo is symptomatic; in the majority of cases the mechanism of the vertigo is unknown and
specific therapy can therefore not be determined. Unless a specific cause of vertigo is known (e.g., Menieres
disease), the choice of pharmacologic agent for treatment depends on the adverse effect profile of the drug,
presence of contraindications and cost. Most drugs used in vertigo down-regulate vestibular excitability (vestibular
suppressants).4 Table 3 describes nonprescription agents used to treat vertigo. Prescription drugs used to treat

vertigo include benzodiazepines,4 betahistine 10 and flunarizine.4 , 8 , 11 Very few drugs (nonprescription or
prescription) have been properly evaluated for the treatment of vertigo.
Table 3: Nonprescription Drugs for Vertigo4
For product selection, consult the tables in Products for Minor Ailments. Gastrointestinal Products:
Antiemetics .
Class

Drug

Dose

Adverse Effects

Comments

Vestibular
dimenhydrinate 2550 mg Q6H po
suppressant/
or 100 mg Q8H pr
antiemetics

Drowsiness, anticholinergic
effects (dry mouth, mydriasis,
blurred vision, constipation,
urinary retention, confusion).

Avoid combining with

C NS depressants.
C ontraindicated in angle
closure glaucoma,
prostatic hypertrophy
and urinary retention.

Vestibular
scopolamine
suppressant/
antiemetics

Transdermal patch
(1.5 mg delivers 1
mg over 3 days) 1
patch Q72H

Drowsiness, anticholinergic
effects (dry mouth, mydriasis,
blurred vision, constipation,
urinary retention, confusion)..
Local reactions/allergies.

Avoid combining with

C NS depressants.
C ontraindicated in angle
closure glaucoma,
prostatic hypertrophy
and urinary retention.

Antiemetics

25 mg Q68H po
for nausea

Drowsiness, anticholinergic
effects (dry mouth, mydriasis,
blurred vision, constipation,
urinary retention, confusion)..
Extrapyramidal reactions.

Avoid combining with

C NS depressants.
C ontraindicated in angle
closure glaucoma,
prostatic hypertrophy
and urinary retention.

promethazine

Although these drugs may reduce vertigo, they also reduce vestibular function in the normal ear, which is a
disadvantage. Vestibular suppressants reduce or slow down vestibular compensation and prevent the C NS from
receiving the necessary feedback to facilitate compensation.4 For this reason, anticholinergics, antihistamines and
benzodiazepines are not intended for long-term use. In most cases the duration of treatment would be a week or
less.

Monitoring of Therapy
Vertigo is often self-limiting. Evaluate the need for continued use of medication daily, at least initially. Determine
the severity, duration and frequency of the vertigo. Monitor the patient for relief of vertigo and associated
symptoms such as nausea, vomiting and anxiety. If no improvement of vertigo is noted, discontinue drug therapy.
Monitor patients for adverse effects such as drowsiness and anticholinergic effects.

Advice for the Patient

C ounsel patients who receive drug therapy regarding:
Expected duration of treatment
Management of side effects (Table 3)
Instructions not to combine drug therapy with alcohol.

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Suggested Readings
Hain TC , Uddin M. Pharmacologic treatment of vertigo. CNS Drugs 2003;17:85-100.
Sloane PD, C oeytaux RR, Beck RS et al. Dizziness: state of the science. Ann Intern Med 2001;134:823-32.

References
1.
2.

3.
4.
5.
6.
7.
8.
9.
10.
11.

Daroff RB. Dizziness and vertigo. In: Fauci AS et al., editors. Harrisons principles of internal medicine. 17th
ed. New York: McGraw-Hill; 2008. p. 139-43.
Lustig LR, Schindler J. Ear, nose and throat disorders. In: McPhee P, McPhee SJ, Papadakis MA, editors.
Current medical diagnosis and treatment 2009. 48th ed. New York: Lange Medical Books/McGraw Hill; 2009.
p.173-208.
Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am 2009;27:39-50.
Hain TC , Uddin M. Pharmacologic treatment of vertigo. CNS Drugs 2003;17:85-100.
Hanley K, ODowd, C onsidine N. A systematic review of vertigo in primary care. Br J Gen Pract 2001;51:66671.
Froehling DA, Bowen JM, Mohr DN et al. The canalith repositioning procedure for the treatment of benign
paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc 2000;75:695-700.
Burgess A, Kundu S. Diuretics for Menieres disease or syndrome. Cochrane Database Syst Rev
2006;3:C D003599.
James AL, Burton MJ. Betahistine for Menieres disease or syndrome. Cochrane Database Syst Rev
2001;1:C D001873.
Strupp M, Zingler VC , Arbusow V et al. Methyprednisolone, valacyclovir, or the combination for vestibular
neuritis. N Engl J Med 2004;351:354-61.
Della Pepa C , Guidetti M, Eandi M. Betahistine in the treatment of vertiginous syndromes: a meta-analysis.
Acta Otorhinolaryngol Ital 2006;26:208-15.
Haid T. Evaluation of flunarizine in patients with Menieres disease. Subjective and vestibular findings. Acta
Otolaryngol Suppl 1988;460:149-53.

Vertigo What You Need to Know

What is vertigo?
Vertigo is a kind of dizziness where it feels like you or your environment is moving or spinning. It often makes
people feel sick to their stomach.
What causes vertigo?
Vertigo can be caused by many things, including viral infections and inner ear problems. Sometimes it goes away
on its own. Other times the body learns to ignore the feeling. Anyone with vertigo should see a doctor to find
out what is causing it.
What is the treatment for vertigo?
Medication can be used to treat vertigo and the upset stomach it causes. However, medications will not fix the
problem. They may even keep your body from learning to ignore the vertigo.
If you suffer from attacks of vertigo, avoid activities that may be dangerous (such as climbing ladders, driving and
operating machinery).
Important information about medications used to treat vertigo:
Medications used to treat vertigo may cause:
drowsiness or blurred visionuse caution driving and operating dangerous machinery
dry mouthsugarless candy or gum may help relieve dryness
constipationdrink plenty of water and eat high-fibre foods
Dont combine these medications with alcohol or other drugs that might make you drowsy or less alert.
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Talk to your pharmacist or doctor if the side effects are unusual or really bother you.

Minor Ailments. Canadian Pharmacists Association, 2012. All rights reserved.

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