Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo

Abstract

IMPORTANCE Acute vertigo can be disabling. Antihistamines and benzodiazepines are frequently prescribed as "vestibular suppressants," but their efficacy is unclear.OBJECTIVE To assess the efficacy of antihistamines and benzodiazepines in the treatment of acute vertigo from any underlying cause.DATA SOURCES We searched the PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and ClinicalTrials.gov databases from inception to January 14, 2019, without language restrictions. Bibliographies of the included studies and relevant reviews were also screened. STUDY SELECTIONWe included randomized clinical trials (RCTs) comparing antihistamine or benzodiazepine use with another comparator, placebo, or no intervention for patients with a duration of acute vertigo for 2 weeks or less. Studies of healthy volunteers, prophylactic treatment, or induced vertigo were excluded, as were studies that compared 2 medications from the same class. DATA EXTRACTION AND SYNTHESIS Following Preferred Reporting Items for SystematicReviews and Meta-analyses (PRISMA) guidelines, data were extracted and risk of bias was assessed by 2 authors independently for each study. Data were pooled using a random-effects model. MAIN OUTCOMES AND MEASURESThe predefined primary outcome was change in 10-or 100-point vertigo or dizziness visual analog scale (VAS) scores at 2 hours after treatment. Secondary outcomes included change in nausea VAS scores at 2 hours, use of rescue medication at 2 hours, and improvement or resolution of vertigo at 1 week or 1 month. RESULTSOf the 27 trials identified in the systematic review, 17 contributed to the quantitative meta-analysis and involved a total of 1586 participants. Seven trials with a total of 802 participants evaluated the primary outcome of interest: single-dose antihistamines resulted in significantly more improvement on 100-point VAS scores compared with benzodiazepines (difference, 16.1 [95% CI, 7.2 to 25.0]) but not compared with other active comparators (difference, 2.7 [95% CI, -6.1 to 11.5]). At 1 week and 1 month, neither daily benzodiazepines nor antihistamines were reported to be superior to placebo. RCTs comparing the immediate effects of medications (at 2 hours) after a single dose generally had a low risk of bias, but those evaluating 1-week and 1-month outcomes had a high risk of bias. CONCLUSIONS AND RELEVANCEModerately strong evidence suggests that single-dose antihistamines provide greater vertigo relief at 2 hours than single-dose benzodiazepines. Furthermore, the available evidence did not support an association of benzodiazepine use with improvement in any outcomes for acute vertigo. Other evidence suggested that daily antihistamine use may not benefit patients with acute vertigo. Larger randomized trials comparing both antihistamines and benzodiazepines with placebo could better clarify the relative efficacy of these medications.

Exposure to anticholinergic and sedative medication is associated with impaired functioning in older people with vertigo, dizziness and balance disorders—Results from the longitudinal multicenter study MobilE-TRA

“…Valid approaches have already been examined and include change of medication as well as nonpharmacological treatment, such as physical exercises or behavioral therapy (Holt et al, 2010). The use of AS medication in symptomatic therapy of VDB remains debated (Hunter et al, 2022). Our results support recent recommendations that their use as vestibular suppressants should be limited only to the acute phase of the disease and must be used with special caution in the older population (Casani et al, 2021).…”

“Do benzodiazepines have a future in treating acute vertigo"

“…There was no evidence to suggest that antihistamines increased the likelihood of complete symptom remission after one week and one month (relative risk, RR = 1.03, 95% CI 0.56–1.89). Authors found fairly persuasive evidence that single-dose antihistamines were superior to benzodiazepines in relieving vertigo symptoms after 2 h. Furthermore, the evidence did not support an association between benzodiazepine use with an improvement in any symptom of acute vertigo at all [ 17 ].…”

Correct Diagnosis for the Proper Treatment of Acute Vertigo—Putting the Diagnostic Horse Before the Therapeutic Cart

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This issue of JAMA Neurology includes a methodologically rigorous systematic review and meta-analysis examining the efficacy of benzodiazepines and antihistamines in patients with acute vertigo. 1 Hunter and colleagues 1 chose an important, common clinical problem, systematically searched for relevant evidence, and then assessed the studies for both quality and risk of bias. Their primary outcome was symptom control of vertigo at 2 hours measured by a visual analog score.

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“…Hunter and colleagues found that antihistamines were superior to benzodiazepines at 2 hours but not at 1 week or 1 month. Importantly, as the authors themselves acknowledge, we do not know if the statistically significant difference in self-rated symptom severity is clinically meaningful.…”

“…Importantly, as the authors themselves acknowledge, we do not know if the statistically significant difference in self-rated symptom severity is clinically meaningful. Of the 16 studies analyzed, 9 of them gave the vestibular suppressant for “1 week to 2 months.” This duration of medication was in the setting of clinical trials; however, in real-life practice, patients often continue treatment with vestibular suppressants for far longer periods of time …”