Published: 2 March 2017

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Medicine-induced Vertigo

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Prescriber Update 38(1): 12-13
March 2017

Vertigo has a number of possible causes, most commonly vestibular neuritis, benign paroxysmal positional vertigo (BPPV) or vestibular migraine, but it can also be caused by medicines^1,2.

Vertigo is a sensation of motion either of the body or the surrounding environment. It occurs when the brain receives conflicting visual, proprioceptive and vestibular information about one’s position in space³.

Vertigo is often described by patients as ‘dizziness’, a non-specific term used to express a variety of sensations that may also include light-headedness, faintness and imbalance, all of which have many possible causes. It is important to distinguish between these symptoms as the cause and management may differ.

Medicines known to Cause Vertigo

A variety of medicines have been associated with vertigo (Table 1).

Some medicines that cause vertigo are also ototoxic (eg, aminoglycosides, anti-inflammatory medicines, phosphodiesterase type-5 inhibitors, furosemide). When a patient who is taking a medicine known to be ototoxic presents with vertigo, dose reduction or discontinuation of the medicine may need to be considered to prevent irreversible hearing loss.

Table 1. Examples of medicines that may cause vertigo (this is not an exhaustive list)

Medicine Class	Examples
Analgesics	codeine
Antibiotics	aminoglycosides, macrolides, minocycline, nitrofurantoin, sulfamethoxazole
Anticonvulsants	levetiracetam, phenytoin, pregabalin
Anti-inflammatories	celecoxib, parecoxib, naproxen, prednisone
Antimalarials	mefloquine, quinine, hydroxychloroquine
Antivirals	oseltamivir, raltegravir
Anti-Parkinson’s drugs	lisuride
Cardiovascular drugs	nifedipine, furosemide, indapamide, prazosin, terazosin, glyceryl trinitrate, isosorbide mononitrate, sotalol, timolol
Gastroenterology drugs	omeprazole, lansoprazole, sucralfate
Rheumatology drugs	zolendronic acid, alendronate
Phosphodiesterase type-5 inhibitors	sildenafil, vardenafil
Other medicines	lithium, haloperidol, benzodiazepines, desmopressin, melatonin

Cases of Vertigo Reported to CARM

The Centre for Adverse Reactions Monitoring (CARM) received 98 case reports of vertigo from 1 January 2006 to 31 December 2015.

The most frequently reported medicine was influenza trivalent vaccine (11 reports). However, only three of the reports gave a clear description of vertigo. In one of these cases, vertigo was associated with severe headache and weakness on one side. In the remaining eight cases, the term vertigo has been used, but it is not clear from the case description whether it was true vertigo or dizziness.

The second most frequently reported medicine was thyroxine (eight reports). The majority of these cases appear to be related to a change in formulation that was introduced in September 2007.

The next most frequently reported medicines are simvastatin (five reports), venlafaxine (five) and omeprazole (four).

As is often the case for medicines with an established safety profile, cases of vertigo associated with medicines that are well known to cause vertigo (eg, aminoglycosides), are rarely reported to CARM.

Vertigo is not listed as an adverse effect in the data sheets of the majority of medicines in the cases reported to CARM. However, it is worth noting, ‘dizziness’ is listed as an adverse effect.

When reporting cases of ‘vertigo’ to CARM, it is helpful to differentiate between true vertigo and other forms of ‘dizziness’. A description of the patient’s symptoms is useful, particularly whether or not the patient experienced a sense of motion (eg, ‘felt that the room was spinning’). This helps CARM and Medsafe to identify whether any update to the medicine’s data sheet is necessary and any further communication is required.

References

1. Drug-induced true vertigo and balance disorders. 2015. Prescrire International. 24(156): 18.
2. Best Practice Advocacy Centre (BPAC). 2012. A delicate balance: managing vertigo in general practice. URL: www.bpac.org.nz/BPJ/2012/september/vertigo.aspx (accessed 22 October 2016).
3. Walker B, Colledge N, Ralston S, et al. 2014. Davidson's Principles and Practice of Medicine 22^nd edition. Edinburgh: Churchill Livingstone.