xRead - Episodic Vertigo (January 2026)

10976817, 2020, S2, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599820909438 by Mayo Clinic Libraries, Wiley Online Library on [19/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Otolaryngology–Head and Neck Surgery 162(2S)

Intentional vagueness: None Role of patient preferences: Large depending on severity of symptoms Exclusions: None

benzodiazepine over the other for vertigo control and simi larly and no evidence for the superiority of the antivertigi nous effects of benzodiazepines when compared with first generation antihistamines. All benzodiazepines carry signifi cant risk for drug dependence. 202,203 Centrally acting anticholinergic drugs (scopolamine and atropine) and glycopyrrolate block muscarinic receptors and can suppress acute vertigo attacks. 196-198,204 Scopolamine is most commonly used in a transdermal formulation created primarily to prevent motion sickness. All anticholinergics can cause blurring of vision, dry mouth, dilated pupils, urin ary retention, and sedation. Because of their side-effect pro file and potential for significant toxicity and withdrawal effects when used for more than several days, they are not commonly prescribed for acute vertigo control associated with MD. There is insufficient evidence demonstrating the relative efficacy of any given class over another. 205-207 STATEMENT 8. SYMPTOM REDUCTION AND PREVENTION: Clinicians should educate patients with Me´nie`re’s disease on dietary and lifestyle modifications that may reduce or prevent symptoms. Recommendation based on RCTs, observation studies, and cohort studies with indeterminate benefit, with preponderance of benefit over harms. Action Statement Profile: 8 Quality improvement opportunity: Identification of MD triggers may reduce symptoms in some patients. Allergies have been shown to contribute to symp toms of MD in up to 30% of the patients. National Quality Strategy domains: Effective Communication and Care Coordination, Person and Family Centered Care, Prevention and Treatment of Leading Causes of Morbidity and Mortality Aggregate evidence quality: Grade C, based on a dearth of RCTs regarding dietary modifications (1 small RCT on sodium restriction, negative for effec tiveness but with study limitations; 1 relatively strong observational/survey study showing advantage to both low sodium and caffeine restriction), 1 RCT regarding decreasing stress hormone vasopressin and 1 RCT of booklet-based symptom control via relaxa tion and cognitive-behavior strategies to reduce anxi ety, 1 RCT regarding an acupressure technique for treatment of dizziness and 2 SRs regarding acupunc ture, 3 RCTs regarding antisecretory therapy (2 posi tive, 1 negative for effectiveness), and a number of observational studies and a strong literature review (human and animal) regarding the role of treatment of allergy symptoms in reducing symptoms of MD in allergic patients. There is a Cochrane SR currently underway for dietary modifications. Level of confidence in evidence: High. Benefits: May improve symptom control, avoid unnecessary lifestyle modifications, improved QOL,

Policy level: Recommendation Differences of opinion: None

Supporting Text The purpose of this statement is to educate clinicians regarding the appropriate use of medications broadly cate gorized as central vestibular suppressants for the control of acute vertigo attacks in patients with MD. Vestibular sup pressants primarily appear to act by suppressing central ves tibular neural activity at the level of the brainstem and concomitantly suppressing nausea. These medications fall into 3 pharmacologic classes—first-generation antihista mines, benzodiazepines, and anticholinergics. It must be emphasized that the utilization of these medications for con trol of vertigo and nausea predated the requirements for evidence-based studies to verify therapeutic efficacy. As such, while these medications are commonly used and are felt to be effective by both patients and clinicians, there is a paucity of peer-reviewed evidence to document their effec tiveness. It must also be stressed that these medications should be used only to suppress acute vertiginous events. Chronic use of these drugs is undesirable, as these agents can suppress central adaptation/compensation to vestibular loss and can thus perpetuate symptoms of chronic imbalance. First-generation antihistamines cross the blood-brain bar rier and bind to several neurotransmitter receptors, including histamine and muscarinic acetylcholine receptors. 196-198 The ability to bind to these various sites likely accounts for their ability to suppress a variety of symptoms, including vertigo and nausea. Commonly used antihistamines include dimen hydrinate (25-50 mg every 6 hours), meclizine (12.5-25 mg every 8 hours), or diphenhydramine (25-50 mg every 6 hours). All these drugs suppress vertigo and nausea likely with equal efficacy. In the United States, diphenhydramine and promethazine (a phenothiazine with antihistaminic properties) are typically the most readily available in an injectable formulation. 199-201 All can cause hypersomno lence, dry mouth, and urinary retention. Benzodiazepines are gamma aminobutyric acid receptor agonists, are also effective at suppressing vertigo, and can thus secondarily mitigate vertigo-associated nausea. 196-198 A large variety of benzodiazepines are available in a variety of formulations. Historically, diazepam (2-10 mg every 8 hours) has been used for vertigo control. 201 There is perhaps a theoretical advantage to the use of lorazepam (1-2 mg every 8 hours) due to its rapid onset of action and shorter half-life. 199,200 Clonazepam (0.5-1.0 mg every 8 hours) has also been used for acute vertigo suppression. 196 Most experts recommend against the use of alprazolam due to tachyphylaxis and complications associated with drug with drawal. 197 There is no evidence for the superiority of 1