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#274 Making your head spin: Betahistine for benign paroxysmal positional vertigo

Is betahistine effective for adults with benign paroxysmal positional vertigo (BPPV)?

When used alone without repositioning maneuvers (i.e. Epley maneuver), limited data suggest more patients have “improved” dizziness with betahistine compared to placebo (75% versus 52% placebo at 3 months). However, betahistine is less effective than Epley. Whether betahistine is effective for residual dizziness post-Epley is uncertain. At best, 44% of patients compared to 21% on placebo will “improve”.

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All randomized, controlled trials (RCTs). Differences statistically significant unless stated. 
  • Betahistine without Epley maneuver:1 
    • Industry-sponsored, double-blind RCT, 63 patients, betahistine 16mg BID or placebo. After 3 months treatment: 
      • Number of patients “improved” (not defined) on vertigo scale: 75% betahistine, 52% placebo. 
        • Headache: 18% (betahistine) versus 3%, not statistically different. 
  • Betahistine compared to Epley maneuver: 
    • 90 patients, betahistinebetahistine plus Epley maneuver, or Epley maneuver (frequencies not stated).2 Baseline vertigo ~7.7 on 11-point scale (lower=better). 
      • After 1 week: 
        • Epley or combination better on vertigo scale: ~2.3 versus ~3.7 (betahistine). 
          • Difference likely clinically relevant. 
    • 96 patients, betahistine 24mg BID or Epley maneuver (performed twice at baseline, repeated after 1 week if needed).3Baseline dizziness disability ~75 on 100-point scale (lower=better). 
      • Disability score after 8 weeks treatment: 20 versus 10 (Epley), significance not reported. 
  • Post-Epley maneuver: 
    • 100 patients with dizziness post-Epley maneuver, randomized to betahistine 24mg BID or no drug.4 After 5 days: 
      • No difference in any outcome. 
    • 78 patients (59 with dizziness post-Epley given up to 4 times/session), randomized (double-blind) to betahistine 16mg TID or placebo.5 After 1 week: 
      • No difference dizziness disability scores. 
      • Patients with “improved” dizziness (not defined): 59% versus 27% (placebo). 
      • Limitations: if used all randomized patients, improvement changes to 44% and 21%, respectively. 
    • 72 patients, double-blind, randomized to Epley, Epley plus placebo, or Epley plus betahistine 24mg bid.6 After 1 week: 
      • Adding betahistine did not significantly change dizziness disability score, vertigo score or number with “persistent symptoms”.  
  • Betahistine adverse effects (mainly gastrointestinal and headache) poorly reported; often similar to placebo.7 
  • Betahistine (16mg) costs ~$25 for 90 tablets.8 

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  • Adrienne J Lindblad BSP ACPR PharmD
  • Shan Lu MD CCFP & Rodger Craig MPH

1. Mira E, Guidetti G, Ghilardi PL, et al. Eur Arch Otorhinolarynghol. 2003 Feb; 260(2):73-7.

2. Kaur J, Shamanna K. Int Tinnitus J. 2017; 21(1):30-4.

3. Maslovara S, Soldo SB, Puksec M, et al. NeuroRehabilitation. 2012; 31:435-41.

4. Acar B, Karasen RM, Buran Y. B-ENT. 2015; 11:117-121.

5. Jalali MM, Gerami H, Saberi A, Razaghi S. Ann Otol Rhinol Laryngol. 2020 May; 129(5):434-40.

6. Guneri EA, Kustutan O. OtolaMryngol Head Neck Surg. 2012 Jan; 146(1):104-8.

7. Murdin L, Hussain K, Schilder AGM. Cochrane Database System Rev. 2016;6:CD010696.

8. Alberta Health, Alberta Blue Cross. Interactive Drug Benefit List. Available at:;jsessionid=Hp5GKqetZ29Z4TcKPQq0O1CZz6qX_S7EKydTKdlp78nowLQwEngv!8486576?searchTerm=betahistine&category=&genericName=&brandName=&ptc=&mfgCode= Accessed August 31, 2020.

Authors do not have any conflicts of interest to declare.