INDEX

Dizziness : An Introduction

Dizziness & Its Associated Symptoms

Different Conditions Contributing to Dizziness

BPPV, Meniere’s disease

Route to symptomatic management

Prochlorperazine : Properties & Role

Comparative Analysis : Cinnarazine

Nutshell Message
 Dizziness : An Introduction

Dizziness is medically
Dizziness is a
defined as an illusion
nonspecific term
of movement or any
used by patients to
abnormal sensation
describe a sensation
of motion between a  Dizziness affects
of altered spatial
patient and his or her
surroundings.1
orientation.1 approximately, 20-30% of
people in the general
population2

Dizziness is seen  Dizziness is the

either as a Dizziness is quintessential symptom
subjective the 3rd most presentation in all of
symptom common
clinical medicine.3
or as a vestibular complaint
disorder that can be among outpatients1
objectified.2

1. Wong J, Philip J, Hilas O. Management of Dizziness and Vertigo. US Pharmacist. Available from; www.medscape.co,/viewarticle/758389_print. Accessed on 8, Aug, 2015.; 2. Brandt T, Dieterich M, Strupp M. Vertigo
and dizziness. 2nd Edition; Springer; pp. 5.; 3. Neurology: Clinical Practice. 2011;24-32.
Dizziness & Its Associated Symptoms

NAUSEA
VOMITING

ANXIETY
 Related Symptom: Nausea and Vomiting

Nausea and vomiting are commonly occurring symptoms.

Nausea and vomiting accounts for 3.2 to 9%

of the patients visiting dizziness center1

Nausea and vomiting significantly affect

quality of life and have a significant
effect on daily activities and cause psychological and
emotional hardship.3

1. Semin Neurol. 2013; 33(03): 185-194. 2. Emerg Med Clin North Am. 2009 Feb; 27(1): 39–viii.; 3. http://www.nidcd.nih.gov/health/balance/pages/balance_disorders.aspx
Etiology & Pathophysiology of Nausea and
Vomiting
Visceral Chemoreceptor Vestibular
stimuli trigger zone input

Dopamine and Dopamine and Histamine and

serotonin serotonin acetylcholine
released released released

Histamine and
acetylcholine
released • Nausea vomiting of vestibular origin acts via
different receptors as compared to that of
other origin.
Nausea and
vomiting • Histamine & acytylcholine receptors are
predominantly involved in Vestibular type.

• Hence anti-histaminic & anti-cholinergic

activity is essential
1. Flake ZA. Practical selection of antiemetics. American family physician,2004; 69(5). 2. Brandt T, Dieterich M, Strupp M. Vertigo and dizziness. ISBN:978-1-85233-814-5(Print)
 Related Symptom : Anxiety

3/5 Dizziness Patients Suffer From Anxiety

Up to 60% of cases
presenting with
chronic dizziness were
found to have primary
or secondary anxiety.1

A higher prevalence of abnormal anxiety in men (23.7%) compared to women

(14.5%) has been observed in dizziness patients.2

1. Otorhinolaryngol Clin Int J. 2012;4(2):77-80. 2. BMC Ear Nose Throat Disord. 2012; 12: 2.
 Different Conditions Presenting As Dizziness

Otological Neurologic
Conditions1 Conditions1

Benign
paroxysmal Migrainous Vertigo
positional vertigo

Vestibular neuritis/ Demyelinating

labyrinthitis diseases

Meniere's disease CNS lesions

Degenerative changes Metabolic/ vascular

in the vestibular / degenerative CNS
labyrinth/ ototoxicity disorders

1. Otolaryngol Clin North Am. 2012 Oct;45(5):925-40.

Case Study 1
Peripheral Vertigo v/s Central Vertigo
Presenting Features
Peripheral vertigo usually does not have CNS related
symptoms and auditory symptoms are more common

• Associated nausea
• Vomiting
• Auditory complaints usually present
• Abrupt onset but slowly improving
• More of a spinning sensation

Central vertigo often produces other neurologic

symptoms, although this generalization has many
exceptions.
• Gradual onset but slowly deteriorating
• Tend to be much less intense than those associated with
peripheral vertigo
• More of instability
Case Study 2
BPPV- Benign paroxysmal
positional vertigo
 BPPV Defined
Additional symptoms can
be treated
 BPPV is the most common cause of
vertigo constituting 20-40% of all
patients with peripheral vestibular
disorder.3
 Benign paroxysmal positional vertigo
(BPPV) is a disorder of the inner ear
characterized by episodes of vertigo
triggered by changes in head position1

 BPPV is thought to be caused by the

presence of otoconia in one or more
semi-circular canals1

Common characteristics of BPPV include rotational vertigo (in 86%), nausea (33%),
vomiting (14%), imbalance (49%), fear of falling (36%).2

1. Otolaryngol Clin North Am. 2012 Oct;45(5):925-40.; 2. Advances in Otolaryngology. 2014; Article ID 792635.
 Symptomatic Management of BPPV:
Why essential?

Pharmacological intervention and symptomatic

improvement in patient with BPPV

9%

91%
No Improvement in Symptom
Improvement in Symptom

Considerable reduction in the severity of vertigo with pharmacological intervention

(about 91% people show improvement in symptom), especially in patients with
BPPV, and vertigo of peripheral origin.1

1. Front Neurol. 2013;4:48.

 Symptomatic management of BPPV:How ?

Medical Therapy
 vestibular suppressant medications

Reduces the intensity of Reduce the associated Effective in managing

vertigo and nystagmus
motion sensitivity and anxiety associated with
evoked by
a vestibular imbalance1
motion sickness1 vertigo1

• Anticholinergics,
Three major vestibular • Antihistamines and Benzodiazepines
(minimize anxiety associated with vertigo).
suppressants are used1
• Prochlorperazine is useful as short-term
treatment of severe non-psychotic anxiety

1. Yacovino DA, Luis L. Pharmacologic Treatment Of Vestibular Disorders. Vestibular Disorders Association. 2014;1-6.
 Guidelines recommending
Symptomatic Management

Vestibular suppressant
medications are recommended Grade C Recommendation,
for short-term management of If unknown or unclear
vegetative symptoms such as benefit in patients with
nausea or vomiting in severely BPPV.
symptomatic patient.1

Clinical Practice Guidelines Vertigo

Vestibular suppressants
in Adults – 2nd Edition
(e.g. benzodiazepines) and
antivertigo drugs (e.g. H3 receptor Grade B Recommendation,
antagonists) may be given for Level 2B Evidence
PHILIPPINE SOCIETY OF
symptomatic relief of patients OTOLARYNGOLOGY-HEAD
with BPPV.2
AND NECK SURGERY, INC.

1. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl 4):S47-81; 2. Philippine Journal Of Otolaryngology-Head And Neck Surgery. 2014;29(Suppl 1):1-16.
 Management of BPPV

 Maneuvers are considered as definitive line of therapy in the

management of BPPV1
 Some of the techniques include2

Maneuver Surgical treatment

• Singular neurectomy
• Epley maneuver
• Vestibular neurectomy
• Semont maneuver • Posterior semicircular canal
• Gufoni maneuver occlusion

1. CMAJ. 2003;169(7):681-693.; 2. Otolaryngology–Head and Neck Surgery. 2008;139(5S4):S47-S81.

Case Study 3
Meniere’s Disease
 Meniere’s Disease

Sustained, Fluctuating
episodic vertigo hearing loss Tinnitus

Ménière’s disease is characterized by discrete episodic attacks, with each

attack exhibiting a characteristic triad of:1

Duration of vertigo lasts longer

usually for hours1

More disabling owing to both

severity and duration1

1. Otolaryngology–Head and Neck Surgery. 2008;139(5S4):S47-S81.

 Symptomatic management Of
Meniere’s Disease

Intense nausea and vomiting are the

dominant symptoms during acute
attacks of vertigo.1

Once an attack is established,

little can be done to alter its natural
course. In such situations, mouth
dissolving prochlorperazine can be taken
even in the presence of intense nausea
as it has a rapid onset of action.1

There is a need for a medication that can

• Strongly act against nausea and
vomiting and
• Be taken without water

1. Medicine Today. 2014;15(3):18-26.

 Guidelines recommending
Symptomatic Management

Clinical Practice Guidelines Vertigo

For acute attacks of vertigo in Adults – 2nd Edition
associated with Meniere’s Grade B
disease, vestibular Recommendation, Level
suppressants and/or anti- 2b Evidence PHILIPPINE SOCIETY OF
vertigo drugs may be given.1 OTOLARYNGOLOGY-HEAD
AND NECK SURGERY, INC.

Vestibular suppressants with anti-nausea effects, such as

prochlorperazine are useful.2

1. Philippine Journal Of Otolaryngology-Head And Neck Surgery. 2014;29(Suppl 1):1-16.; 2. Medicine Today. 2014;15(3):18-26.
 Management Of Meniere’s Disease
Aims of management
 To reduce the frequency and severity of symptoms
 To improve the quality of life of patients and their families

Treatment options for Ménière’s disease

Complete
destruction
Vestibular of the inner
nerve ear
Aminoglyco- section
Surgery of Side
endolymphatic injections
Diuretics/
Betahistine/ sac
Low-salt
diet Corticosteroids

1. Medicine Today. 2014;15(3):18-26.

 Management Of Meniere’s Disease

Medications for Noninvasive

vertigo therapies and
• Motion sickness procedures
medications • Rehabilitation
• Anti-nausea • Hearing aid
medications
• Meniett device

Middle ear Surgery

injections • Endolymphatic sac
• Gentamicin procedures
• Steroids • Vestibular nerve
section
• Labyrinthectomy

1. Medicine Today. 2014;15(3):18-26.

 Drug treatment of Dizziness/Vertigo

Drug therapy is aimed at :-

Providing symptomatic relief from

the nausea and vomiting through
1 vestibular suppressants like
prochlorperazine which controls
symptoms fast.

Treatment of the underlying cause

of the vertigo; for this a proper
diagnosis is required which is

2 possible from a thorough history

taking, clinical tests and some
investigations called vestibular
function tests.

1. Am Fam Physician. 2005 Mar 15;71(6):1115-1122.

 Drug treatment of Dizziness/Vertigo

A wide variety of medications are used to treat vertigo and the frequently concurrent
nausea and emesis.1

These medications exhibit various combinations of acetylcholine, dopamine, and

histamine receptor antagonism. 1

Classes of medications useful in the treatment of vertigo include anticholinergics,

antihistamines, benzodiazepines, calcium channel antagonists and dopamine receptor
antagonists. These medications often have multiple actions. 1

The American Gastroenterological Association

recommends anticholinergics and antihistamines for the
treatment of nausea associated with vertigo or motion
sickness. 1

1. Am Fam Physician. 2005 Mar 15;71(6):1115-1122.

 Vestibular Suppressants

Vestibular suppressants reduce the asymmetry in the vestibular tone between the
ears and thereby reduce vertigo1

• Anticholinergics- acts on muscarinic receptors (M3 & M5)

Vestibular suppressants exhibits mechanism of action
• Anti-histaminies- H1- receptors
by inhibiting various receptors1
and calcium channel antagonists
• Dopaminergic- Dopamine
receptors
• Benzodiazepines- GABA receptors
1. Otorhinolaryngol Clin. 2012;4(2):81–85.; 2. Rad za medicinske znanosti, Zagreb. 2007;6:69-76.
 Vestibular Suppressants

Vestibular suppressants include

• Benzodiazepines (Diazepam)
• Antihistaminies (Prochloperazine, Dimenhydrinate, Cinnarizine)
• Anticholinergics (Scopolamine)
• Antiemetics (Dexamethasone, Domperidone, Metoclopromide)

Vestibular suppressants should be used for a few days at most because they delay
the brain's natural compensatory mechanism for peripheral vertigo.2

1. Otorhinolaryngol Clin. 2012;4(2):81–85.; 2. Rad za medicinske znanosti, Zagreb. 2007;6:69-76.

Which one to choose and why?
 Prochlorperazine
The best drug for symptomatic relief is prochlorperazine as it acts by inhibiting the
vestibular nuclei or by blocking the receptors in the cholinergic pathways or by
sedating the central nervous system.1

Prochlorperazine has anticholinergic and antidopaminergic effects and hence not only
relieves the patient from the very debilitating rotating/spinning sensation but also
from the accompanying vegetative symptoms. 1

Anti-
Anti-cholinergic Antihistaminic Antiserotonergic
dopaminergic

Mouth
dissolving
Prochlorperazine short-term treatment is effective in managing symptoms benefit offers
such as dizziness, nausea, vomiting and non-psychotic anxiety.2 rapid onset of
action

Therapy with anti-vertigo drugs MUST be continued only as long as the symptoms
persist.1

1. Anirban Biswas. VERTIGO - and what is New in it from the General Physician’s Perspective. 2. API
 Prochlorperazine vs. Cinnarizine
Percentage of weekly improvement of subjective symptoms

95
92.85 94.16 93.33
90
85
80 81.25

75
70
Central Peripheral
N = 25
P < 0.05
Prochlorperazine Cinnarizine

Prochlorperazine is superior to cinnarizine in the treatment of

vertigo irrespective of the central or peripheral vertigo.1

1. IJO & HNS. 1998;50(4):392-397.

 Prochlorperazine vs. Cinnarizine

Property Prochlorperazine1 Cinnarizine2,3

Common side-
Hypotension Pedal oedema, drowsiness
effects

• Extrapyramidal symptoms
(EPS)
Rare side-effects Occasional EPS (1%)
• Parkinsonism (Long-term
effect)

1. API.; 2. J Chem Pharm Res. 2010;2(3):381-386. 3. Clin Drug Invest. 2005;25(6):377-389.

 Prochlorperazine vs. Cinnarizine

Property Prochlorperazine1 Cinnarizine2,3

• Antihistaminic (H1)
• Anti cholinergic • Cinnarizine – Ca+ channel blocker
MoA • Anti dopaminergic with local vasodilatation (H1
• Vestibulo-suppressant antagonist);
• Anti-emetic
• Very effective drug for
• Reasonably symptomatic relief.
symptomatic relief
• Enhances blood supply in brain /
Efficacy • CNS depressant- hence very
inner ear
likely to inhibit vest. Comp.
• Likely to inhibit vest. Comp. Mech.
Mech.

1. API.; 2. J Chem Pharm Res. 2010;2(3):381-386. 3. Clin Drug Invest. 2005;25(6):377-389.

In A Nut Shell
The Key Points To Takeaway

Dizziness is never alone but accompanied by nausea, vomiting,

anxiety and other symptoms.

Both BPPV and Meniere’s disease require emergent management and

vestibular suppressants prove useful for the same.

Comprehensive management of BPPV and Meniere’s disease

incorporate maneuvers and exercise, but for symptomatic relief,
pharmacotherapy is required.

Prochlorperazine is the best drug for symptomatic relief and

is superior to cinnarizine in the treatment of vertigo.

Prochlorperazine mouth dissolving should be preferred during

intense nausea, as it has a rapid onset of action.
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Jaypee Brother takes the responsibility for the content provided
herewith.The information provided is not intended to be a
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Never disregard professional medical advice, or delay in seeking it
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In Association with

Dr.Milind V.Kirtane Dr.Kashmira P.Chavan

Consultant ENT Surgeon
P.D.Hinduja National Hospital,
Breach Candy Hospital,
Saifee Hospital
Mumbai .
Consultant ENT Surgeon
Dr.L.H.Hiranandani Hospital
Powai ,Mumbai