Pharmacological treatment of vertigo

Comparison of the therapeutic efficacy of a fixed low-dose combination of cinnarizine and dimenhydrinate with betahistine in vestibular neuritis: a randomized, double-blind, non-inferiority study

BACKGROUND

Vestibular neuritis (VN) is a strongly disabling disease of the peripheral vestibular system. Rapid and effective relief of symptoms is important to allow patients to promptly return to normal physical activity.

OBJECTIVE

The aim of this prospective, randomized, double-blind study was to evaluate the efficacy of a fixed low-dose combination of cinnarizine and dimenhydrinate in unilateral VN in comparison with betahistine in terms of improvement of vertigo and concomitant symptoms, and performance in neurotological testing.

METHODS

Sixty-two patients were randomized to receive either cinnarizine 20 mg/dimenhydrinate 40 mg as a fixed combination or betahistine 12 mg, each three times daily for 4 weeks. Vertigo and concomitant symptoms, activities of daily living (ADL), posturography and a battery of vestibulo-ocular tests, registered by electronystagmography including spontaneous nystagmus, bithermal caloric and rotatory test, among others, were assessed at baseline (t(0)), after 1 week (t(1w)) and after 4 weeks (t(4w)). The primary endpoint was the Mean Vertigo Score (MVS) at t(1w), a composite of 12 individual scores for unprovoked and provoked vertigo, each assessed using a 10 cm visual analogue scale (VAS). Non-inferiority of the fixed combination versus betahistine would be assumed if the two-sided 95% confidence intervals (CIs) for between-group differences in MVS lay entirely below the non-inferiority margin of 1.25 (12.5% of VAS range).

RESULTS

The fixed combination led to significantly greater improvements in MVS than betahistine both at t(1w) (primary endpoint) and at t(4w) (95% CI for the difference in baseline-adjusted means -0.95, -0.64 at t(1w), -0.77, -0.44 at t(4w); p < 0.001). Vegetative symptoms and ADL also improved significantly more under the fixed combination than under betahistine at t(1w) (p < 0.001, each parameter) and t(4w) (p < 0.001 and p < 0.01, respectively), both showing a nearly complete remission at t(4w). In the two groups, pathological posturography and electronystagmography parameters normalized during the 4-week treatment. The fixed combination group showed an earlier recovery of spontaneous nystagmus than the betahistine group (t(1w), p < 0.001) and slightly higher improvements in asymmetry of rotation-induced nystagmus at t(1w) and t(4w) (p = 0.041, each time point). No significant differences were found between the treatments in abatement of spontaneous nystagmus at t(4w) and decrease of caloric lateralization or improvement of equilibrium (sensory organization test [SOT], conditions 5/6) at t(1w) and t(4w). No patient reported any adverse event.

CONCLUSION

The results showed that the fixed low-dose combination of cinnarizine and dimenhydrinate is an effective and well tolerated option for symptomatic treatment in unilateral VN. The fixed combination led to significant improvements in vertigo and ADL within the first week, and to a nearly complete recovery after 4 weeks. Neurotological testing revealed no signs of a possible detrimental influence of the 4-week treatment with the fixed combination compared with betahistine in terms of recovery of caloric responsiveness and abatement of rotation-induced nystagmus.

Pharmaceutical countermeasures have opposite effects on the utricles and semicircular canals in man

INTRODUCTION

Sensory conflicts in the vestibular system lead to motion sickness of which space motion sickness (SMS) is a special case. SMS affects up to 70% of the astronauts during the first 3 days in space. The search for effective countermeasures has led to several nonpharmacological and pharmacological approaches. The current study focuses on the effects of lorazepam (1 mg), meclizine (25 mg), promethazine (25 mg), and scopolamine (0.4 mg) on the vestibular system, with special focus on the canal and otolith functions separately.

METHODS

The study had a placebo-controlled, single blind, repeated measures design. Sixteen healthy volunteers were subjected to a total of 7 test sessions, the first and last being without intake of medication. Semicircular canal function was evaluated by means of electronystagmography and otolith function with unilateral centrifugation. The horizontal semicircular canal function was characterized by the vestibulo-ocular reflex (VOR) gain measured during earth vertical axis rotation as well as the total caloric response. The function of the utricles was represented by the utricular sensitivity, reflecting the ocular counter roll relative to the virtual induced head tilt.

RESULTS

Promethazine significantly decreased the semicircular canal and utricular parameters. Both scopolamine and lorazepam caused only a decrease in the utricular sensitivity, whereas meclizine only decreased the semicircular canal-induced VOR gain.

DISCUSSION

The results show that the drugs affected different areas of the vestibular system and that the effects can thus be attributed to the specific pharmacological properties of each drug. Meclizine, as an antihistaminergic and weak anticholinergic drug, only affected the VOR gain, suggesting a central action on the medial vestibular nucleus. The same site of action is suggested for the anticholinergic scopolamine since acetylcholine receptors are present and utricular fibers terminate here. The global vestibular suppression caused by promethazine is probably a consequence of its anticholinergic, antihistaminergic, and antidopaminergic properties. Based on the fact that lorazepam increased the affinity of gamma-aminobutyric acid (GABA) for the GABA(A)-receptor and its effects on the utriculi, the site of action seems to be the lateral vestibular nucleus.

CONCLUSION

Meclizine, scopolamine, and lorazepam selectively suppress specific parts of the vestibular system. Selective suppression of different parts of the vestibular system may be more beneficial for alleviating (space) motion sickness than general suppressive agents. Additionally, this knowledge may help the clinician in his therapeutic management of patients with either semicircular canal or otolith dysfunction.

Epley's manoeuvre versus Epley's manoeuvre plus labyrinthine sedative as management of benign paroxysmal positional vertigo: prospective, randomised study

Introduction:

We report a prospective, randomised study of 51 patients with benign paroxysmal positional vertigo treated with Epley's manoeuvre alone or Epley's manoeuvre plus labyrinthine sedative, at Sundaram Medical Foundation, Chennai, India.

Aim:

To compare the efficacy of Epley's manoeuvre versus Epley's manoeuvre plus labyrinthine sedative in the treatment of benign paroxysmal positional vertigo.

Materials and methods:

Consecutive patients were selected based on history and positive Dix–Hallpike test. Patients were randomised to receive either Epley's manoeuvre alone or Epley's manoeuvre plus labyrinthine sedative for one week. Both groups were followed up for four weeks.

Results:

Univariate analysis showed that one- and four-week outcomes were influenced by the number of episodes, symptom duration and treatment type. Multivariate logistic regression analysis showed that the one-week outcome was significantly influenced by symptom duration and treatment type, while the four-week outcome was significantly influenced by symptom duration alone. Patients receiving Epley's manoeuvre alone showed better recovery than those receiving both Epley's manoeuvre and labyrinthine sedative.

Conclusion:

Labyrinthine sedatives do not aid recovery from benign paroxysmal positional vertigo when used in addition to Epley's manoeuvre.

Pharmacodynamic differentiation of lorazepam sleepiness and dizziness using an ordered categorical measure

Categorical measures of lorazepam sleepiness and dizziness were modeled to identify differences in pharmacodynamic (PD) parameters between these adverse events (AEs). Differences in data-derived PD parameters were compared with relative incidence rates in the drug label (15.7% and 6.9%, respectively). Healthy volunteers (n = 20) received single oral doses of 2 mg lorazepam or placebo in a randomized, double-blind, cross-over fashion. A seven-point categorical scale measuring the intensity of AEs was serially administered over 24 h. The maximum score (MaxS), and area under the effect curve (AUEC) were determined by noncompartmental methods and compared using a paired t-test. Individual scores were modeled using a logistic function implemented in NONMEM. AUEC and MaxS for sleepiness were significantly higher than dizziness (20.35 vs. 9.76, p < 0.01) and (2.35 vs. 1.45, p < 0.01). Model slope estimates were similar for sleepiness and dizziness (0.21 logits x mL/ng vs. 0.19 logits x mL/ng), but baseline logits were significantly higher for sleepiness (-2.81 vs. -4.34 logits). Data-derived PD parameters were in concordance with label incidence rates. The higher intensity of sleepiness may be directly related to baseline (no drug present) while the increase in intensity as a result of drug was relatively similar for both AEs.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is characterized by brief recurrent episodes of vertigo triggered by changes in head position. BPPV is the most common etiology of recurrent vertigo and is caused by abnormal stimulation of the cupula by free-floating otoliths (canalolithiasis) or otoliths that have adhered to the cupula (cupulolithiasis) within any of the three semicircular canals. Typical symptoms and signs of BPPV are evoked when the head is positioned so that the plane of the affected semicircular canal is spatially vertical and thus aligned with gravity. Paroxysm of vertigo and nystagmus develops after a brief latency during the Dix-Hallpike maneuver in posterior-canal BPPV, and during the supine roll test in horizontal-canal BPPV. Positioning the head in the opposite direction usually reverses the direction of the nystagmus. The duration, frequency, and symptom intensity of BPPV vary depending on the involved canals and the location of otolithic debris. Spontaneous recovery may be expected even with conservative treatments. However, canalithrepositioning maneuvers usually provide an immediate resolution of symptoms by clearing the canaliths from the semicircular canal into the vestibule.

Neuropharmacology of vestibular system disorders

This work reviews the neuropharmacology of the vestibular system, with an emphasis on the mechanism of action of drugs used in the treatment of vestibular disorders. Otolaryngologists are confronted with a rapidly changing field in which advances in the knowledge of ionic channel function and synaptic transmission mechanisms have led to the development of new scientific models for the understanding of vestibular dysfunction and its management. In particular, there have been recent advances in our knowledge of the fundamental mechanisms of vestibular system function and drug mechanisms of action. In this work, drugs acting on vestibular system have been grouped into two main categories according to their primary mechanisms of action: those with effects on neurotransmitters and neuromodulator receptors and those that act on voltage-gated ion channels. Particular attention is given in this review to drugs that may provide additional insight into the pathophysiology of vestibular diseases. A critical review of the pharmacology and highlights of the major advances are discussed in each case.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

Objectives:

This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV.

Purpose:

The primary purposes of this guideline are to improve quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology–head and neck surgery, physical therapy, and physical medicine and rehabilitation.

Results

The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. ® 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

A fixed combination of cinnarizine/dimenhydrinate for the treatment of patients with acute vertigo due to vestibular disorders : a randomized, reference-controlled clinical study

BACKGROUND AND OBJECTIVE

Vestibular dysfunction commonly leads to - often severe - vertigo symptoms. The objective of this study was to compare the antivertiginous efficacy and tolerability of a fixed combination of cinnarizine/dimenhydrinate with those of betahistine in patients with acute vertigo due to vestibular disorders.

METHODS

Sixty-six patients experiencing acute vertigo attacks participated in this prospective, double-blind, three-centre, comparative study. Patients who assessed at least one vertigo symptom as being of medium intensity (> or =2) on a 5-point visual analogue scale (VAS; from 0 = no symptoms to 4 = very severe symptoms) were randomly allocated to treatment with the fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg three times daily or betahistine 12 mg three times daily for 4 weeks. The primary efficacy endpoint was change in mean vertigo score, as determined by patients' assessments of 12 individual vertigo symptoms on the 5-point VAS after 4 weeks of treatment.

RESULTS

Treatment with the fixed combination led to significantly greater improvements in mean vertigo scores than the reference therapy betahistine after 4 weeks of therapy (p = 0.013). The differences were clinically relevant, based on the Mann-Whitney estimator. Furthermore, the incidence of vertigo-associated vegetative symptoms was significantly reduced after 1 (p = 0.004) and 4 weeks (p = 0.023) in the fixed-combination group relative to the betahistine group. Three patients, all of them in the betahistine group, reported adverse events, none of which was considered serious. Almost all patients (n = 62) rated the tolerabilities of both medications as very good or good.

CONCLUSION

The fixed combination of cinnarizine/dimenhydrinate was shown to be an effective and very well tolerated treatment option for patients with acute vertigo due to vestibular disorders. The combination proved to be significantly more efficient in reducing vertigo and associated vegetative symptoms than betahistine in such patients.

Improving the quality of life in patients with vestibular disorders: the role of medical treatments and physical rehabilitation

Vertigo, dizziness and imbalance are the main symptoms of vestibular disorders. They can lead to physical consequences, such as reduced postural control and falls, to psychologic/psychiatric consequences, such as anxiety-depression symptoms, panic and agoraphobia, and to cognitive defects, especially in the elderly. Consequently, the general health status and the quality of life (QoL) of vestibular patients can be significantly impaired. Several questionnaires have been developed in an attempt to quantify the degree of handicap and disability, the self-perceived health status and the quality of life in vestibular patients with dizziness and imbalance. Additionally, the main goal of the treatments of vestibular disorders should be to control symptoms, reduce functional disability and to improve patients' QoL. This article reviews the physical and psychological consequences of the vestibular disorders, their impact on the patients' QoL, and the treatment options, including drug prescriptions and vestibular rehabilitation protocols. A profile of the compound betahistine and its efficacy on QoL indices in the treatment of Menière's disease and other forms of peripheral vertigo is also presented.

A support vector machines approach for virtual screening of active compounds of single and multiple mechanisms from large libraries at an improved hit-rate and enrichment factor

Support vector machines (SVM) and other machine-learning (ML) methods have been explored as ligand-based virtual screening (VS) tools for facilitating lead discovery. While exhibiting good hit selection performance, in screening large compound libraries, these methods tend to produce lower hit-rate than those of the best performing VS tools, partly because their training-sets contain limited spectrum of inactive compounds. We tested whether the performance of SVM can be improved by using training-sets of diverse inactive compounds. In retrospective database screening of active compounds of single mechanism (HIV protease inhibitors, DHFR inhibitors, dopamine antagonists) and multiple mechanisms (CNS active agents) from large libraries of 2.986 million compounds, the yields, hit-rates, and enrichment factors of our SVM models are 52.4-78.0%, 4.7-73.8%, and 214-10,543, respectively, compared to those of 62-95%, 0.65-35%, and 20-1200 by structure-based VS and 55-81%, 0.2-0.7%, and 110-795 by other ligand-based VS tools in screening libraries of >or=1 million compounds. The hit-rates are comparable and the enrichment factors are substantially better than the best results of other VS tools. 24.3-87.6% of the predicted hits are outside the known hit families. SVM appears to be potentially useful for facilitating lead discovery in VS of large compound libraries.

Optimizing the pharmacological component of integrated balance therapy

Summary

Drug treatment is an important option for the treatment of peripheral vestibular diseases.

Aim

To identify the drug component associated with optimal integrated balance therapy (IBT) for Ménière's disease or other peripheral vestibular disorders.

Materials and Methods

Analysis of a series of patients with Ménière's disease patients or patients with other peripheral vestibular disorders that received IBT involving either no medication or betahistine, cinnarizine, clonazepam, flunarizine or Ginkgo biloba during 120 days.

Results

In Ménière's disease, significant differences were observed for all drug therapies (60 days) versus no medication; betahistine was significantly more effective than all other drugs at 60 and 120 days. For non-Ménière's disorders, significant differences were observed among betahistine, cinnarizine, clonazepam and flunarizine and no medication after 60 days; all drug therapies were significantly more effective than no medication after 120 days; betahistine, cinnarizine or clonazepam were equally effective and betahistine was more effective than flunarizine and EGb 761. All treatment options were well tolerated.

Conclusions

Drug therapies were more effective than no medication in the IBT for patients with Ménière's disease or other peripheral vestibular disorders. Betahistine was the most effective medication for patients with Ménière's disease and was as effective as cinnarizine and clonazepam for other peripheral vestibular disorders.

Efficacy and tolerability of a fixed low-dose combination of cinnarizine and dimenhydrinate in the treatment of vertigo: a 4-week, randomized, double-blind, active- and placebo-controlled, parallel-group, outpatient study

BACKGROUND

Most cases of vertigo are attributable to both peripheral and central vestibular disorders. Therefore, it would be of interest to determine whether a combination therapy having both peripheral and central actions would translate into more efficient symptom relief.

OBJECTIVE

This study was conducted to evaluate the efficacy and tolerability of a fixed low-dose combination of cinnarizine 20 mg + dimenhydrinate 40 mg in the treatment of vertigo of central, peripheral, or combined central/peripheral origin.

METHODS

This was a prospective, multicenter, randomized, double-blind, active- and placebo-controlled, parallel-group, outpatient study in men and women (age >30 years) with central, peripheral, or combined central/peripheral vestibular vertigo. Patients who assessed > or =1 vertigo symptom as being of medium intensity (> or =2) on a 5-point visual analog scale (from 0 = no symptoms to 4 = very severe symptoms) and who had abnormal vestibulospinal movement patterns on cramocorpography were eligible. Patients were randomly assigned to receive 1 tablet of the fixed combination of cinnarizine 20 mg + dimenhydrinate 40 mg, cinnarizine 50 mg, dimenhydrinate 100 mg, or placebo 3 times daily for 4 weeks. The primary efficacy end point was the decrease in mean vertigo score (MVS), which was composed of 12 individual vertigo symptoms, each assessed on the 5-point visual analog scale after 4 weeks of treatment.

RESULTS

The study enrolled 246 patients, of whom 239 were evaluable for efficacy. Approximately two thirds of the efficacy population were female and one third male. The mean age was 51.3 years, and the mean duration of vertigo was 2.6 years. The least squares mean (SD) change from baseline in MVS was significantly greater in the group receiving the fixed combination (1.37 [0.66]) than in any of the comparator groups (cinnarizine 50 mg: 0.87 [0.53]; dimenhydrinate 100 mg: 0.83 [0.66]; placebo: 0.76 [0.48]; all comparisons, P < 0.001). The differences were clinically relevant, based on the Mann-Whitney estimator. The incidence of vertigo-associated nausea was significantly reduced in the fixed-combination group relative to the comparator groups (P< or = 0.016). Thirty-four patients reported adverse events, 6 each in the fixed combination and placebo groups, 12 in the cinnarizine group, and 10 in the dimenhydrinate group. None of these adverse events were considered serious. After 4 weeks of treatment, the tolerability of treatment was rated as very good or good by 57 (96.6%) patients in the fixed-combination group; the values for cinnarizine, dimenhydrinate, and placebo were 54 (93.1%), 42 (72.4%), and 50 (87.7%), respectively.

CONCLUSIONS

In this study, the fixed low-dose combination of cinnarizine 20 mg + dimenhydrinate 40 mg was effective, clinically beneficial, and well tolerated in patients with vestibular vertigo of central and/or peripheral origin. It was significantly more effective in reducing the MVS compared with placebo and the routinely prescribed higher doses of cinnarizine (50 mg) and dimenhydrinate (100 mg).

Prescribing to older ED patients

The purpose of this article is to assist emergency physicians in selecting safe and effective drug therapy for seniors. Because safer alternatives exist, medications on the Beers list of potentially inappropriate medications should generally be avoided. We also review risks associated with several classes of medications: nonsteroidal anti-inflammatory drugs, benzodiazepines, and anticholinergic medications. They are associated with adverse outcomes when taken by older adults and should be used with caution. We also address the use of opioid medications in seniors. Although they are not without risk, opioids are generally safe with slow titration, precautions, and a bowel regimen to prevent constipation. Prescribers should also consider the need for estimating creatinine clearance when prescribing medications that require dosage adjustment in the setting of renal insufficiency. Two areas in need of research are identifying the proper dosing and safety of medications in seniors and prescribing with electronic decision support to assist in prescribing decisions.

Fluoxetine for vestibular dysfunction and anxiety: a prospective pilot study

Anxiety states and disorders amplify the symptoms and impairment associated with vestibular dysfunction. Five patients with inner ear vestibular dysfunction and anxiety were prospectively treated with fluoxetine, 20-60 mg/day, and received an extensive battery of assessments at baseline and after 12 weeks of treatment. Fluoxetine led to significant or near significant reductions in anxiety measures and in impairment due to dizziness; improvements in clinical balance function and vestibular function were less clear. The data add to the literature suggesting a role for selective serotonin reuptake inhibitors in the treatment of dizziness and anxiety.

Effects of cinnarizine on calcium and pressure-dependent potassium currents in guinea pig vestibular hair cells

In vestibular hair cells, K+ currents induced by rises in hydrostatic pressure have recently been demonstrated. These currents are inhibited by charybdotoxin, a blocker of Ca2+-dependent K+ channels. On the other hand, cinnarizine is a blocker of voltage-gated Ca2+ currents in hair cells and is used as a drug in conditions with vestibular vertigo. Our aim was to test in patch-clamp experiments (conventional whole-cell mode) whether cinnarizine, by reducing Ca2+ influx, inhibited Ca2+ and pressure-sensitive K+ currents in vestibular type-II hair cells of guinea pigs. A quantitatively similar inhibition of K+ currents was evoked by extracellular Ca2+ removal, cinnarizine (0.5 microM), and the L-type Ca2+ channel blocker nifedipine (3 microM). Cinnarizine abrogated increases of K+ currents induced by increases in the hydrostatic pressure (from 0.2 to 0.5 cm H2O). At a higher concentration (1 microM), cinnarizine elicited K+ current inhibitions larger than those elicited by Ca2+ removal. Moreover, it reduced K+ currents in the absence of Ca2+, in contrast to nifedipine. However, charybdotoxin abolished these effects of cinnarizine. We thus conclude that cinnarizine inhibits, by two mechanisms, pressure-induced currents that are sensitive to charybdotoxin and Ca2+. It reduces Ca2+ influx and exerts a Ca2+-independent inhibition, with a lower IC50 than that required for Ca2+ channel blockade. These two actions may importantly contribute to its therapeutic effects.

Treatment of vertigo due to acute unilateral vestibular loss with a fixed combination of cinnarizine and dimenhydrinate: a double-blind, randomized, parallel-group clinical study

BACKGROUND

Acute unilateral vestibular loss is a balance disorder that is accompanied by vertigo symptoms and concomitant vegetative symptoms, including nausea and vomiting. Patients are frequently confined to bed rest but may continue to experience vertigo symptoms. A well-established antivertiginous therapy consisting of cinnarizine and dimenhydrinate at low doses may offer rapid relief of acute vertigo symptoms due to acute vestibular loss, without inhibiting physiological compensation processes.

OBJECTIVE

The purpose of this study was to compare the clinical efficacy and tolerability of a fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg versus monotherapy with its respective components in the treatment of acute vertigo symptoms due to acute unilateral vestibular loss.

METHODS

In this prospective, single-center, randomized, double-blind, parallel-group clinical study, 50 patients with acute vestibular vertigo were randomly assigned to receive 4 weeks of treatment (1 tablet 3 times daily) with a fixed combination of 20 mg cinnarizine and 40 mg dimenhydrinate, 20 mg cinnarizine alone, or 40 mg dimenhydrinate alone. All patients received a 15% mannitol infusion as standard therapy during the first 6 days of treatment. Efficacy was determined by the patients' assessments of vertigo symptoms after 1 and 4 weeks of treatment using a verbal rating scale (vertigo score) and by vestibulo-ocular and vestibulospinal tests. The primary efficacy criterion was defined as the relief of vertigo symptoms after 1 week of treatment.

RESULTS

After 1 week of treatment, the fixed combination was significantly more effective than 20 mg cinnarizine (P < 0.001) and 40 mg dimenhydrinate (P < 0.01). After 4 weeks, the fixed combination was still significantly more effective than cinnarizine in reducing vertigo symptoms (P < 0.01) and significantly more effective than dimenhydrinate in improving the patients' balance while standing (P < 0.05). The tolerability of the fixed combination was rated good or very good by 100% of the patients (cinnarizine alone, 82.4%; dimenhydrinate alone, 94.4%). No serious adverse events occurred. Four patients in the fixed combination and the cinnarizine groups, and 6 patients in the dimenhydrinate group reported nonserious adverse events.

CONCLUSIONS

The results of this study suggest a distinct benefit in using a fixed combination of cinnarizine 20 mg and dimenhydrinate 40 mg versus the respective monotherapies in this population of patients with acute vestibular vertigo.

Specific vestibular exercises in the treatment of vestibular neuritis

Introduction Vestibular neuritis rapidly damages unilateral vestibular periphery, inducing severe balance disorders. In most cases, such vestibular imbalance is gradually restored to within the normal level after clinical therapies. This successive clinical recovery occurs due to regeneration of vestibular periphery and/or accomplishment of central vestibular compensation. Rehabilitation The program of vestibular rehabilitation presents a major achievement in the field of treatment of balance disorders. Vestibular compensation is associated with central sensory reintegration and bilaterally equalizes the vestibular tonus over a period of time. Material and methods In this retrospective study of a series of cases authors present their results in 58 patients undergoing a program of vestibular rehabilitation. Patients were divided into two groups. Thirty patients were in group I, and 28 in group II. Specific vestibular exercises were conducted in group I, and non-specific exercises in group II. Analysis of effects of vestibular compensation was made due electronystagmography. Results Results were satisfactory in both groups of patients. Absence of spontaneous nystagmus was detected in 83.3% of patients in group I (specific vestibular exercises) and in 53.5% of patients in group II (non-specific exercises), with an average treatment time of up to 2 months. Harmonization of pendular stimulation was detected in 83.3% and 60.7% of patients in groups I and II, respectively. Conclusion Early physiotherapeutic vestibular rehabilitation supports the vestibular compensation mechanism. At the same time vestibular rehabilitation may prevent panic disorder caused by hyperventilation syndrome.