• Sameer Sharif, Danya Khoujah, Alisha Greer, James G Naples, Suneel Upadhye, and Jonathan A Edlow.
• Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.
• Acad Emerg Med. 2023 May 1; 30 (5): 541551541-551.

BackgroundBenign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Medication use for its treatment remains common despite guideline recommendations against their use.ObjectivesThe 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).MethodsWe 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.ResultsFive 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.ConclusionsIn 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.© 2022 Society for Academic Emergency Medicine.

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