Treatment of vertigo in the neurological practice
Keywords:
vertigo, etiology, pathogenesis, treatmentAbstract
Vertigo is common in the neurological practice as it is a symptom of different syndromes, and not a single disease.
It is caused by a neurosensory informational conflict, due to wrong sensory afferentation from the vestibular system. The etiology is connected with disturbances of the peripheral or central nervous system. Most common are the benign paroxysmal positional vertigo (BPPV), acute vestibular neuronitis and labyrinthitis, Meniere’s disease and psychogenic vertigo.
BPPV is the most common vertigo, caused by trauma or infection. It is due to free movement of the dislodged crystals in the utriculus in semicircular channels.
It is presented by sudden brief episodes of dizziness, triggered by changes in head and body position.
Meniere’s syndrome is the second most common vertigo, caused by endolymphatic hydrops. It is presented by episodic vertigo, autonomic symptoms, sensoneural hearing loss, tinnitus and feeling of ear fullness.
Treatment of vertigo is symptomatic, with antagonists of the calcium channels, antihistamines, histamine analogs, diuretics and benzodiazepines. Meclizine is a H1 receptor antagonist with antihistaminic and central anticholinergic effects. It is effective for the vertigo and vomiting in daily dosage of 100 mg. Betahistine is histamine analog, powerful H3 receptor antagonist, and weak H1 receptor agonist. Betahistine is a drug with very controversial efficacy, due to lack of scientific data. There are no randomized, large, placebo controlled and multicenter clinical trials. However, despite of the lacking data for efficacy Betahistine is widely used in the clinical practice.
The fixed combination of cinnarizine 20 mg and dimenhydrinat 40 mg has better effect on vertigo, autonomic symptoms and nystagmus, as compared to betahistine.
Benzodiazepines are effective for vertigo, but due to the sedative effect interfere with the vestibular compensation.
There are no data that confirm the efficacy of diuretics.
In conclusion there is not a big progress in clarifying the pathogenesis and treatment of vertigo during the last years. The first line treatment is still the fixed combination of cinnarizine и dimenhydrinate. The wide used treatment with betahistine doesn’t has scientific background to confirm its efficacy.
References
Adrion, C., Fischer, C.S., Wagner, J., Gürkov, R., Mansmann, U., Strupp, M., BEMED Study Group. Efficacy and safety of betahistine treatment in patients with Meniere’s disease: primary results of a long term, multicentre, double blind, randomised, placebo controlled, dose defining trial (BEMED trial). BMJ, 2016, 352, h6816.
Biswas, A., Dutta, N. Role of Betahistine in the management of vertigo. Ann. Otol. Neurotol., 2018, 1, 51-57.
Chen, Z.P., Zhang, X.Y., Peng, S.Y., Yang, Z.Q., Wang, Y.B., Zhang, Y.X., Chen, X., Wang, J.J., Zhu J.N. Histamine H1 receptor contributes to vestibular compensation. Journal of Neuroscience, 2019, 39, 3, 420-433.
Cirek, Z., Schwarz, M., Baumann, W., Novotny, M. Efficacy and tolerability of a fixed combination of cinnarizine and dimenhydrinate versus betahistine in the treatment of otogenic vertigo: a double-blind, randomised clinical study. Clin. Drug. Investig., 2005, 25, 377-389.
Crowson, M.G., Patki, A., Tucci, D.L. A systematic review of diuretics in the medical management of Ménière’s disease. Otolaryngol. Head Neck Surg., 2016, 154, 824-834.
Dyhrfjeld‐Johnsen, J., Attali, P. Management of peripheral vertigo with antihistamines: New options on the horizon. Br. J. Clin. Pharmacol., 2019, 85, 2255-2263.
Gananca, M.M., Caovilla, H.H., Gananca, F.F., Gananca, C.F., Munhoz, M.S.L., da Silva, M.L.G., Serafini, F. Clonazepam in the pharmacological treatment of vertigo and tinnitus. International Tinnitus Journal, 2002, 8, 1, 50-53.
Hahn, A., Novotný, M., Shotekov, P.M., Cirek, Z., Bognar-Steinberg, I., Baumann, W. Comparison of cinnarizine/dimenhydrinate fixed combination with the respective monotherapies for vertigo of various origins: a randomized, double-blind, active-controlled, multicentre study. Clin. Drug Investig., 2011, 31, 6, 371-383.
Halker, R.B., Barrs, D.M., Wellik, K.E., Wingerchuk, D.M., Demaerschalk, B.M. Establishing a diagnosis of benign paroxysmal positional vertigo through the dixhallpike and side-lying maneuvers: a critically appraised topic. Neurologist, 2008, 14, 3, 201-204. 10.Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia, 2018, 38, 1, 1–211.
James, A., Burton Martin, J. Betahistine for Ménière’s disease or syndrome. Cochrane Database of Systematic Reviews. Hoboken, N.J., John Wiley & Sons, Ltd, 2001.
Kirtane, M.V., Bhandari, A., Narang, P., Santani, R. Cinnarizine: a contemporary review. Indian J. Otolaryngol. Head Neck Surg., 2019, 71, Suppl. 2, 1060-1068.
Lacour, M. Betahistine treatment in managing vertigo and improving vestibular compensation: clarification. J. Vestib. Res., 2013, 23, 3, 139-151. 14.Lacour, M., van de Heyning, P.H., Novotny, M., Tighilet, B. Betahistine in the treatment of Ménière’s disease. Neuropsychiatr. Dis. Treat., 2007, 3, 4, 429-440.
Lee, C., Jones, T.A. Neuropharmacological targets for drug action in vestibular sensory pathways. J. Audiol. Otol., 2017, 21, 3, 125-132.
Lezius, F., Adrion, C., Mansmann, U., Jahn, K., Strupp, M. High-dosage betahistine dihydrochloride between 288 and 480 mg/day in patients with severe Menière’s disease: a case series. Eur. Arch. Otorhinolaryngol., 2011, 268, 8, 1237-1240.
Liu, Y., Yang, J., Duan, M. Current status on researches of Meniere’s disease: a review. Acta Oto-Laryngologica, 2020, 140, 10, 808-812.
Lopez-Escamez, J.A., Carey, J., Chung, W.H., Goebel, J.A., Magnusson, M., Mandalà, M., Newman-Toker, D.E., Strupp, M., Suzuki, M., Trabalzini, F., Bisdorff, A., Classification Committee of the Barany Society, Japan Society for Equilibrium Research, European Academy of Otology and Neurotology (EAONO), Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), Korean Balance Society. Diagnostic criteria for Menière's disease. J. Vestib. Res., 2015, 25, 1, 1-7.
Maslovara, S., Kosec, A. Post-COVID-19 benign paroxysmal positional vertigo. Case Reports in Medicine, 2021.
Murdin, L., Hussain, K., Schilder, A.G.M. Betahistine for symptoms of vertigo. Database Syst. Rev., 2016, 2016, 6, CD010696.
Neuhauser, H.K. The epidemiology of dizziness and vertigo. Handb. Clin. Neurol., 2016, 137, 67-82.
Oberman, B.S., Patel, V.A., Cureoglu, S., Isildak, H. The aetiopathologies of Ménière's disease: a contemporary review. Acta Otorhinolaryngol. Ital., 2017, 37, 4, 250-263.
Otto, V., Fischer, B., Schwarz, M., Baumann, W., Preibisch-Effenberger, R. Treatment of vertebrobasilar insufficiency-associated vertigo with a fixed combination of cinnarizine and dimenhydrinate. Int. Tinnitus J., 2008, 14, 1, 57-67.
Parnes, L.S., Agrawal, S.K., Atlas, J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ, 2003, 169, 7, 681-693.
Plescia, F., Salvago, P., Dispenza, F., Messina, G., Cannizzaro, E., Martines, F. Efficacy and pharmacological appropriateness of cinnarizine and dimenhydrinate in the treatment of vertigo and related symptoms. Int. J. Environ. Res. Public Health, 2021, 18, 9, 4787.
Rahlfs, V.W., Zimmermann, H. The Mean Vertigo Score (MVS) outcome scale and its use in clinical research for quantifying vestibular disorders. Front. Neurol., 2021, 12.
Scholtz, A.W., Hahn, A., Stefflova, B., Medzhidieva, D., Ryazantsev, S.V., Paschinin, A., Kunelskaya, N., Schumacher, K., Weisshaar, G. Efficacy and safety of a fixed combination of cinnarizine 20 mg and dimenhydrinate
mg vs betahistine dihydrochloride 16 mg in patients with peripheral vestibular vertigo: a prospective, multinational, multicenter, double-blind, randomized, non-inferiority clinical trial. Clin. Drug. Investig., 2019, 39, 11, 1045-1056.
Scholtz, A.W., Ilgner, J., Loader, B., Pritschow, B.W., Weisshaar, G. Cinnarizine and dimenhydrinate in the treatment of vertigo in medical practice. Wien Klin Wochenschr., 2016, 128, 9, 341-347.
Scholtz, A.W., Steindl, R., Burchardi, N., Bognar-Steinberg, I., Baumann, W. Comparison of the therapeutic efficacy of a fixed low-dose combination of cinnarizine and dimenhydrinate with betahistine in vestibular neuritis: a randomized, double-blind, noninferiority study. Clin. Drug Investig., 2012, 32, 6, 387-399.
Taghdiri, F., Togha, M., Razeghi Jahromi, S., Refaeian, F. Cinnarizine for the prophylaxis of migraine associated vertigo: a retrospective study. Springerplus, 2014, 3, 1, 231.
Thirlwall, A.S., Kundu, S. Diuretics for Ménière’s disease or syndrome. Cochrane Database Syst. Rev., 2006, 3, Cd003599.
Van Esch, B., van der Zaag-Loonen, H., Bruintjes, T., van Benthem, P.P. Betahistine in Ménière’s disease or syndrome: a systematic review. Audiol. Neurotol., 2022, 27, 1-33.
Wibble, T., Engström, J., Verrecchia, L., Pansell, T. The effects of meclizine on motion sickness revisited. Br. J. Clin. Pharmacol., 2020, 86, 8, 1510-1518.
You, P., Instrum, R., Parnes, L. Benign paroxysmal positio nal vertigo. Laryngoscope Investig. Otolaryngol., 2019, 4, 1, 116-123.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2021 Ivan Milanov
This work is licensed under a Creative Commons Attribution 4.0 International License.
