Pharmacotherapy of Vestibular Disorders and Nystagmus

Abstract

Vertigo and dizziness are with a life-time prevalence of ~30% among the most common symptoms and are often associated with nystagmus or other oculomotor disorders. The prerequisite for a successful treatment is a precise diagnosis of the underlying disorder. In this overview, the current pharmacological treatment options for peripheral and central vestibular, cerebellar, and oculomotor disorders including nystagmus are described. There are basically seven groups of drugs that can be used (the "7 As"): antiemetics; anti-inflammatory, anti-Menière's, and antimigraine medications; antidepressants, anticonvulsants, and aminopyridines. In acute vestibular neuritis, recovery of the peripheral vestibular function can be improved by treatment with oral corticosteroids. In Menière's disease, a long-term high-dose treatment with betahistine-dihydrochloride (at least 48 mg three times daily) had a significant effect on the frequency of the attacks; the underlying mode of action is evidently an increase in inner-ear blood flow. The use of aminopyridines is a well-established therapeutic principle in the treatment of downbeat and upbeat nystagmus as well as episodic ataxia type 2 and cerebellar gait disorders. As was shown in animal experiments, these potassium channel blockers increase the activity and excitability and normalize irregular firing of cerebellar Purkinje cells. They evidently augment the inhibitory influence of these cells on vestibular and deep cerebellar nuclei. A few studies showed that baclofen improves periodic alternating nystagmus; gabapentin and memantine improve pendular and infantile nystagmus. However, many other eye-movement disorders such as ocular flutter, opsoclonus, central positioning, and see-saw nystagmus are still difficult to treat. Although substantial progress has been made, further state-of-the-art trials must still be performed on many vestibular and oculomotor disorders, namely Menière's disease, vestibular paroxysmia, vestibular migraine, and many forms of central eye-movement disorders.

Central ocular motor disorders, including gaze palsy and nystagmus

“…Finally, we describe the two most common forms of nystagmus and the current therapeutic approaches: DBN and UBN [66], and their treatment with aminopyridines [58, 67, 68]. Both are types of fixation nystagmus that, in contrast to other types of peripheral vestibular spontaneous nystagmus, can hardly be suppressed by gaze fixation, which instead increases them, leading to blurred vision and oscillopsia.…”

Effects and safety profile of betahistine in patients in the Russian contingent of OSVaLD, an open-label observational study in vestibular vertigo

“…Also untested in OSVaLD was the impact of higher doses of betahistine, especially in Ménière’s disease. It is widely considered that a betahistine dose of 48 mg three times daily should be used in individuals with this condition, 22 which is three times higher than the dose examined in OSVaLD (48 mg/day); doses of up to 480 mg/day have reportedly been used successfully in severe cases. 23 It is possible, therefore, that the beneficial effects of betahistine on HRQoL in our database are not a full representation of the effects that might be achieved.…”

Effects and tolerability of betahistine in patients with vestibular vertigo: results from the Romanian contingent of the OSVaLD study

“…Also untested in OSVaLD was the possible effect of higher doses of betahistine in Ménière’s disease. It is widely held (see, for example, Strupp et al 30 ) that the appropriate dosage of betahistine in this condition is 48 mg three times daily, ie, three times the dose examined in OSVaLD. Even higher doses (up to 480 mg/day) have been used with benefit in severe cases.…”