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Three Part Question

In [patients with benign paroxysmal peripheral vertigo], does [betahistine] [reduce residual dizziness after canalolith repositioning]?

Clinical Scenario

A 44 year old woman with recurrent episodes of benign paroxysmal peripheral vertigo (BPPV) presents to the ED. You perform a successful Epley manoeuvre but are unsure if there is anything you can prescribe her for residual dizziness as an outpatient.

Search Strategy

MEDLINE and Embase using the OVID interface.

(exp Vertigo/ or exp Benign Paroxysmal Positional or vertigo.mp) AND (exp Betahistine/ or Serc.mp. or Betaserc.mp. or Vergo.mp. or antihistamine.mp. or exp Histamine Antagonists/).

Search Outcome

422 papers found, of which 417 were considered irrelevant and 1 was considered relevant with results not yet accessible. The remaining 4 papers are discussed below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kaur et al. 2017 India	60 patients with BPPV & successful Epley manoeuvre Betahistine 16 mg TID (30) vs control (30)	RCT	Dizziness Handicap Inventory score score (Day 1 and 7 of treatment)	(No statistically significant change in dizziness scores between groups p>0.05) (Data presented graphically without raw numerical data)	Did not present raw values for DHI scores No analysis of heterogeneity of comorbidities between groups Small sample size
Acar et al. 2015 Turkey	50 patients with BPPV & successful Epley manoeuvre Betahistine 24 mg BID (25) vs control (25)	RCT	Dizziness Handicap Inventory score (Day 1, 3, and 5 of treatment)	Betahistine Day 1: 61.44 (± 22.09) Day 5: 23.68 (± 18.24) No medication Day 1: 69.04 (± 17.28) Day 5: 13.52 (±11.06) (No statistically significant change in dizziness scores between groups p>0.05)	No analysis of heterogeneity of comorbidities between groups Small sample size

Comment(s)

There are many studies that investigate the effectiveness of betahistine in peripheral vertigo in general but fewer that examine BPPV specifically. Of the few studies that do exist, all have small sample sizes and many lack assessment of heterogeneity between groups. Three of four included studies show no difference between use of the Epley manoeuvre alone and additionally prescribing betahistine. The one study that showed higher reduction of dizziness scores had a disproportionate prevalence of hypertension in the treatment group which was shown to be associated with a higher rate of improvement, potentially skewing results. The abstract of the RCT for which the full text and results are not yet available in English further suggest that betahistine does not significantly improve residual dizziness compared to no medications.

Clinical Bottom Line

There is insufficient robust evidence to recommend advise against the use of betahistine in patients with BPPV with a successful Epley manoeuvre. The evidence from the small RCTs captured in this search largely suggests that there is no benefit from betahistine use but also do not assess the associated adverse effects of this medication. Further research on the topic is required before recommendations can be made.

References

1. Jalali MM, Gerami H, Saberi A, Razaghi S. The Impact of Betahistine versus Dimenhydrinate in the Resolution of Residual Dizziness in Patients with Benign Paroxysmal Positional Vertigo: A Randomized Clinical Trial. Annals of Otology, Rhinology & Laryngology. 2020 May;129(5):434-40.
2. Kaur J, Shamanna K. Management of benign paroxysmal positional vertigo: a comparative study between Epleys manouvre and Betahistine. The international tinnitus journal. 2017 Apr 3;21(1):30-4.
3. Acar B, Karasen RM, Buran Y. Efficacy of medical therapy in the prevention of residual dizziness after successful repositioning maneuvers for benign paroxysmal positional vertigo (BPPV). B-ENT. 2015 Jan 1;11(2):117-21.
4. Guneri EA, Kustutan O. The effects of betahistine in addition to epley maneuver in posterior canal benign paroxysmal positional vertigo. Otolaryngology - Head and Neck Surgery. 2012 Jan;146(1):104-8.