Management of Vertigo in the Emergency Department

Diagnosis-Based Approach

The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends against routine use of vestibular suppressants, such as antihistamines or benzodiazepines, for Benign Paroxysmal Positional Vertigo (BPPV) 2
The Epley maneuver is recommended as the first-line therapy for BPPV, following confirmation of diagnosis with the Dix-Hallpike test 2

Vestibular suppressants should only be used for short-term management of severe symptoms, not as definitive therapy, according to the American College of Emergency Physicians 1
For acute Meniere's disease attacks, vestibular suppressants should only be used during the acute attack, not as continuous therapy 1
Physical therapy, such as the Epley maneuver, is prioritized over medication for BPPV 2

The use of vestibular suppressants is an independent risk factor for falls, particularly in elderly patients, as noted by the American Geriatrics Society 1
Significant side effects of vestibular suppressants include drowsiness, cognitive deficits, and impaired driving ability 1
Long-term use of vestibular suppressants can hinder central vestibular compensation, according to the Vestibular Disorders Association 1

Do not use meclizine or antihistamines for BPPV, as they are ineffective and delay compensation, according to the American Academy of Otolaryngology-Head and Neck Surgery 2
Do not use vestibular suppressants on a scheduled/continuous basis; use only as needed for acute symptoms, as recommended by the American College of Emergency Physicians 1
Avoid routine CT/MRI brain scans for BPPV without neurologic red flags, as suggested by the American Academy of Neurology 2
Avoid long-term benzodiazepine use due to the risk of dependence, according to the American Society of Addiction Medicine 3