Sharif S, Khoujah D, Greer A, et al. Vestibular suppressants for benign paroxysmal positional vertigo: A systematic review and meta-analysis of randomized controlled trials. Acad Emerg Med. 2022 Oct 21. doi: 10.1111/acem.14608. (Systematic review)

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Medication use for its treatment remains common despite guideline recommendations against their use.

OBJECTIVES: The objective was to evaluate the efficacy and safety of vestibular suppressants in patients with BPPV compared to placebo, no treatment, or canalith repositioning maneuvers (CRMs).

METHODS: We searched MEDLINE, Cochrane, EMBASE, and ClinicalTrials.gov from inception until March 25, 2022. for randomized controlled trials (RCTs) comparing antihistamines, phenothiazines, anticholinergics, and/or benzodiazepines to placebo, no treatment, or a CRM.

RESULTS: Five RCTs, enrolling 296 patients, were included in the quantitative analysis. We found that vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up (14-31 days in four studies) when evaluated as a continuous outcome (standardized mean difference -0.03 points, 95% confidence interval [CI] -0.53 to 0.47). Conversely, CRMs may improve symptom resolution at the point of longest follow-up as a dichotomous outcome when compared to vestibular suppressants (relative risk [RR] 0.63, 95% CI 0.52 to 0.78). Vestibular suppressants had an uncertain effect on symptom resolution within 24 h (mean difference [MD] 5 points, 95% CI -16.92 to 26.94), repeat emergency department (ED)/clinic visits (RR 0.37, 95% CI 0.12 to 1.15), patient satisfaction (MD 0 points, 95% CI -1.02 to 1.02), and quality of life (MD -1.2 points, 95% CI -2.96 to 0.56). Vestibular suppressants had an uncertain effect on adverse events.

CONCLUSIONS: In patients with BPPV, vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up; however, there is evidence toward the superiority of CRM over these medications. Vestibular suppressants have an uncertain effect on symptom resolution within 24 h, repeat ED/clinic visits, patient satisfaction, quality of life, and adverse events. These data suggest that a CRM, and not vestibular suppressants, should be the primary treatment for BPPV.

Discipline Area Score
Emergency Medicine 7 / 7
Internal Medicine 6 / 7
Neurology 5 / 7
Comments from MORE raters

Emergency Medicine rater

An important and novel synthesis of the literature. It's important for clinicians to know how poor the long-term benefits of suppressants seem to be and the advantages of CRV. I am a little unclear as to how the term "uncertain" is used to describe outcomes like adverse events and what it means in more quantitative terms.

Emergency Medicine rater

Acute dizziness in the emergency department is one of the most confounding diagnoses in emergency medicine and a consistently frustrating experience for patients. Emergency medicine physicians demonstrate significant diagnostic and therapeutic heterogeneity in evaluating and treating acute dizziness. This systematic review provides quantitative proof about the lack of effectiveness of pharmacological "vestibular suppressants" relative to canalith repositioning maneuvers and ought to be a siren call for evolving the approach to these patients in ED settings.

Neurology rater

This meta-analysis included a few small single-center RCTs with low-certainty evidence. The paper concludes that the recommendation against medication for BPPV is congruent with guidelines in ENT and neurology. There is not much certain or new here.
Comments from EvidenceAlerts subscribers

Mr. Henry Siem (11/20/2022 10:41 AM)

Confirms previous studies on vestibular suppressants. Meclizine is still being prescribed because prescribing an ineffective medication gives the impression you're doing something rather than teaching an effective maneuver and ordering the patient to repeat the maneuver until symptom resolution.