Benadryl for vertigo: Spinning out of control: Vertigo
Spinning out of control: Vertigo
Vertigo isn’t just a catchy song by the band U2, but is also a common symptom that has multiple potential causes. Although most people think that vertigo has to involve a spinning sensation, vertigo is actually the sensation that one is moving or that one’s surroundings are moving in the absence of any actual movement. To understand vertigo, one must understand that our sense of balance comes from multiple different systems in the body.
A balancing act: processing system inputs
There is your visual system, which tells you where your body is in space and time in relation to your surroundings. There is the sensory system, which allows your feet to send information to your brain about the terrain you are walking on. A third system, the vestibular system, often goes unappreciated in day-to-day life, but can cause havoc when not working properly. The vestibular system is composed of structures in your inner ear that function like a carpenter’s level.
Like a level, when the device is tilted in one direction or another, the bubble moves indicating imbalance. Similarly, during head and body movements, the inner ear transmits information regarding movement or balance to the brain. When there is a mismatch between the visual, sensory, or vestibular systems, people can at times have balance issues. Those balance issues can include vertigo.
Medications for the treatment of vertigo are used to target structures in the brain that process these at times conflicting signals. Antihistamines like dimenhydrinate (Dramamine), diphenhydramine (Benadryl), and meclizine (Antivert) can be useful treatments for vertigo. Anticholinergic medications like scopolamine can be particularly useful, as it comes in a patch form, which can be applied just prior to entering a situation where motion sickness can be anticipated.
One of the most common manifestations of vertigo occurs when someone travels on a boat. While on a boat, particularly when not standing on the deck, your visual system indicates that there is not much movement, and your surroundings appear still. The vestibular system (inner ear), on the other hand, is telling your brain that there is back and forth rocking movement, which naturally occurs with sea travel. The result is that one part of the brain is registering movement while the other part of the brain is registering no movement. This mismatch leads to vertigo, nausea, and at times vomiting, which is commonly known as seasickness.
Unfortunately, when people feel seasick many go below deck to lie down, which makes the problem worse. The best remedy for seasickness is actually to go above the deck, and look at the motion of the water or off at the horizon. By doing this, the visual system perceives the motion that the vestibular system perceives, which can alleviate the sense of imbalance. For many who have experienced seasickness, the symptoms can persist for hours to days after getting off the boat. Another place where such balance mismatches frequently occur is when transitioning onto or off of an escalator.
I explained this concept to one of my patients who is an avid fisherman as he complained about his wife, who frequently gets seasick. After providing the advice, he said, “Dr. Mathew, your care has been life-changing. As a thank you, you must join me on my boat some day.” I replied, “Thank you for the offer, but I am horrible at fishing.” He said, “Oh really, why is that?” I replied, ‘’Because it is difficult to catch any fish when you are holding two cocktails.” He chuckled, and proceeded to tell me about how he often catches mackerel, which other fishermen call inedible, advising him to throw it back in the water. He ignores their advice and keeps the mackerel, noting, “My wife loves that greasy fish.” I then asked him, “Is fishing a religious experience for you?” He said, “No doctor, why do you ask?” I then shrugged my shoulders and said, “Holy mackerel?” As he tried to hide a smile, he indicated that he was not amused. I then said, “Like the mackerel, I guess I should have thrown that bad joke overboard”, which caused him to laugh out loud. Apparently, the post-punch line was a bigger hit than the actual punch line.
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How to Get Rid of Vertigo Once and For All
Physical therapy to improve balance and inner ear issues
Vestibular rehabilitation is a type of physical therapy that can benefit people with inner ear or balance problems. It helps your brain learn ways to use other senses (such as vision) to compensate for vertigo.
The exercises are typically customized to meet a person’s individual needs. They may include eye and head movements, balance training, or other maneuvers, depending on what’s causing your symptoms.
Vestibular rehabilitation is usually performed on an outpatient basis, but it can also be done in a hospital or home setting. (1)
—also known as the Epley Maneuver
Canalith repositioning, also known as the “Epley maneuver,” is a technique that involves a series of special head and body movements.
The purpose is to move crystals from the fluid-filled semicircular canals of your inner ear to a different area, so they can be absorbed by the body.
Canalith repositioning involves the following steps:
- You sit on an exam table with your eyes open and your head turned 45 degrees to the right.
- You lie on your back quickly with your head hanging off the end of the table.
- Your doctor turns your head 90 degree to the left, and you hold this position for about 30 seconds.
- Your physician turns your head another 90 degrees to the left while you rotate your body in the same direction. This position is held for another 30 seconds.
- You sit up on the left side of the exam table.
- The procedure can be repeated on both sides until you feel relief.
You’ll probably have symptoms of vertigo during your treatment. You might need to remain upright for 24 hours following your procedure to prevent crystals from returning to the semicircular canals.
A doctor or physical therapist typically performs canalith repositioning, but you may be shown how to do modified exercises at home.
Canalith repositioning is very effective for people with benign paroxysmal positional vertigo (BPPV) — the most common cause of vertigo. Results vary, but some studies have shown between a 50 and 90 percent success rate. (2)
If the crystals move back into your semicircular canals, your doctor can repeat the treatment.
You should tell your healthcare provider if you have any of the following before having this therapy:
- A neck problem
- A back condition
- Rheumatoid arthritis
- A detached retina in your eye
- Blood vessel or heart problems (3,4)
Related: YouTube Videos May Help Some Vertigo Patients
Medication that targets the cause of our symptoms
Various medicines are used to help improve symptoms of vertigo. Drugs are typically more effective at treating vertigo that lasts a few hours to several days.
People with Ménière’s disease may benefit from taking diuretics, medicines that help your body get rid of salt and water.
If your vertigo is caused by an infection, antibiotics or steroids may be given.
Sometimes doctors recommend antihistamines, such as Antivert (meclizine), Benadryl (diphenhydramine), or Dramamine (dimenhydrinate) to help vertigo episodes. Anticholinergics, such as the Transderm Scop patch, may also help with dizziness.
Anti-anxiety meds, like Valium (diazepam) and Xanax (alprazolam) may help relief vertigo in some people, especially if symptoms are triggered by an anxiety disorder.
If your vertigo is caused by a stroke, you may need drugs, such as aspirin, Plavix (clopidogrel), Aggrenox (aspirin-dipyridamole), or Coumadin (warfarin) to prevent a future event.
Certain medication to treat migraines may also help vertigo symptoms in some people. These might include various medicines from different drug classes, such as antidepressants, beta-blockers, selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, anti-emetics, or calcium channel blockers.
Several other medicines are used to help symptoms of vertigo. Check with your doctor to see which drugs might be appropriate for your particular condition. (2)
—an uncommon treatment for special cases
Surgery isn’t a common treatment for vertigo, but it’s sometimes needed.
You might require a surgical procedure if your symptoms are caused by an underlying condition, such as a tumor or an injury to your brain or neck.
In rare circumstances, doctors may suggest canal plugging surgery for people with BPPV when other treatments fail. With this procedure, a bone plug is used to block an area of your inner ear and prevent the semicircular canals from responding to particle movements. The success rate is around 90 percent. (3)
Another surgery, called labyrinthectomy, disables the vestibular labyrinth in your bad ear and allows the other ear to control balance. This procedure is rarely done but may be recommended if you have significant hearing loss or vertigo that hasn’t responded to other therapies.
Rarely, people with Meniere’s disease may also require surgery, such as a shunt surgery, to help symptoms.
A procedure to plug a leak in the inner ear is sometimes used for individuals with perilymph fistula.
Other surgical procedures may be necessary, depending on what’s causing your vertigo episodes.
—when other treatments haven’t worked
In cases in which patients have not responded to other treatments, injections are sometimes used to help people with vertigo symptoms. The antibiotic Gentamicin (garamycin) can be injected into your inner ear to disable balance. This allows the unaffected ear to perform the balance functions.
Psychotherapy can help alleviate the stress of symptoms
Some people with vertigo may benefit from psychotherapy, even if their symptoms aren’t caused by a psychiatric disorder. (4)
Psychotherapy, also known as “talk therapy,” helps you identify negative behaviors and replace them with positive solutions. There are several different types of psychotherapy.
You may need to be treated for an underlying problem
Your doctor might recommend other treatments for your vertigo, depending on the underlying problem that’s causing your symptoms.
For instance, people with conditions such as heart disease, diabetes, multiple sclerosis (MS), Parkinson’s disease, and anemia may develop vertigo. You might need specific treatments to target these diseases.
Related: The Most Surprising Symptoms of Multiple Sclerosis
Sometimes vertigo goes away all on its own
Your vertigo may go away on its own, with no specific treatment. For instance, people with BPPV often notice that their symptoms disappear within a few weeks or months. (3)
Your doctor can help you figure out if treatment is necessary for your condition.
Treatment Options for Dizziness | San Francisco Audiology
There are many possible causes for dizziness and vertigo symptoms, including:
- Benign paroxysmal positional vertigo (BPPV)
- Meniere’s disease
- Ear infection
- Multiple sclerosis
- Medication toxicity
- Viral meningitis
Once your doctor has determined the underlying cause of your dizziness/vertigo, you can begin treatment. Below are some of the most common dizziness treatments.
Vestibular Rehabilitation Therapy
Vestibular rehabilitation therapy (VRT) is an effective method for reducing dizziness and vertigo. During this treatment, you’ll work with a physical therapist who will create an exercise-based program focused on improving balance, reducing dizziness and overcoming vertigo.
The Epley maneuver is effective for treating BPPV, a condition that causes dizziness due to calcium crystals becoming dislodged in the inner ear. During this treatment, your doctor will walk you through a series of body movements designed to move the crystals to a less sensitive area where they can be reabsorbed by the body.
Studies have shown that sodium, caffeine and alcohol intake can affect your balance. In fact, many have turned to a low-sodium diet to prevent dizziness caused by Meniere’s disease, a condition that causes episodes of hearing loss, dizziness and tinnitus. If you are experiencing dizziness, try to limit your intake of these substances.
Allergic episodes cause many symptoms, including nausea, vomiting, dizziness and diarrhea, among others. If your dizziness is allergy-related, an antihistamine such as Benadryl may help.
One study published in 2018 in Otology & Neurotology found that medications that prevent migraines, including tricyclic antidepressants, can be effective in decreasing dizziness and vertigo.
Extreme anxiety can cause people to feel symptoms of dizziness and vertigo. According to the American College of Cardiology, sedatives such as Valium, Ativan and Xanax can reduce these symptoms by calming brain activity, thus reducing anxiety and related issues.
If you have Meniere’s disease, diuretics (also called water pills) may prevent buildup of endolymph fluid in the inner ear, which can cause dizziness.
Drink More Water
Dehydration is a major cause of dizziness, according to the Mayo Clinic. To prevent episodes of dizziness, drink at least 64 ounces of water a day, and try to avoid dehydrating substances like alcohol, salty foods and caffeine.
For more information or to talk to a doctor about treating your symptoms of dizziness and vertigo, call the experts at San Francisco Audiology today.
Learn More About Ear Disorders
Drug treatment of Vertigo
Doses are all those used routinely for adults, and will generally not be
appropriate for children. Pregnancy category varies from
A (controlled human studies have failed to demonstrate a risk to the fetus)
through D (there is positive evidence of human fetal risk, use only in a life-threatening
situation or for a serious disease for which safer drugs cannot be used or are
Anticholinergics which affect muscarinic receptors, such as scopolamine,
increase motion tolerance. The action appears to be mainly central, although there are receptors in both the periphery and centrally. Anticholinergics also affect compensation, producing a
reversible overcompensation if administered after compensation has been attained to a
vestibular imbalance (Zee, 1988). The mixed antihistamine/anticholinergic drugs are often available OTC, or “over the counter”. Examples are meclizine, dimenhydrinate, and diphenhydramine. The antihistamine component has side effects of sleepiness and long term weight gain (see below). Thus it makes some sense to use prescription anticholinergics rather than OTC mixed drugs (such as meclizine). Hyoscyamine, which is the L-isomer of atropine, is a common ingrediant in antispasmodic treatments for IBS. Hyoscine, or scopolamine, is mainly used in the patch form to prevent motion sickness.
Agents with central anticholinergic effects are most
important in treating vertigo, since anticholinergic drugs that do not cross the
blood-brain barrier are ineffective in controlling motion sickness (Takeda et al, 1989).
Unlike antihistamines which will be discussed subsequently, pure anticholinergics are
ineffective if administered after symptoms have already appeared.
All anticholinergics used in the management of vertigo have prominent side
effects of dry mouth, dilated pupils, and sedation. They all make it harder to think as well as acetylcholine is an important neurotransmitter in the brain. Scopolamine and atropine
are nonspecific muscarinic receptor antagonists (Barton et al, 1994; Soto et al, 2013). Diphenidol (Vontrol), is also an anticholinergic, although little used in the US. There are also some reports of scopolamine inducing migraine, as well as a withdrawall syndrome. There is no reason to believe that any one nonselective ACH antagonist (e.g. scopolamine) is better than any other ACH antagonist (e.g. meclizine, hyocyamine, and many other antihistamines), but scopolamine has no central antihistamine component (which is associated with sleepiness and weight gain). Oral versions of scopolamine would seem equally likely to work as patches (e.g. oral drugs for IBS) for motion sickness, but there currently is no oral version of scopolamine (hyoscine). The atrophine derivitive, hyocyamine (L-atropine), can be used instead.
Cholinergic agonists that cross into the brain, such as physostigmine, can cause a motion-sickness syndrome (Soto et al, 2013). Cholinergic agonists that do not cross into the brain such as neostigmine, do not produce motion sickness. It is
to be hoped that agents selective for vestibular subtypes of muscarinic receptors will eventually be developed or discovered among our presently available pharmacopoeia,
as these agents may provide vestibular suppression with less side effects.
Addiction is possible to the anticholinergics. This has been described
for scopolamine (Luetje and Wooten 1996), and other anticholinergics
may also have addiction syndromes. Withdrawal has been described from a similar agent to meclizine, diphenhydramine. Overdose is similar to acute psychosis. Hospitalization may then precipitate withdrawal. (Thomas et al, 2009). Addiction to the patch can be managed by withdrawall, sometimes facilitated by use of oral agents containing hyocyamine.
Antihistamines. While the precise role of histamine in central vestibular
processing is uncertain, there are data indicating that centrally acting antihistamines
prevent motion sickness and reduce the severity of its symptoms even if taken
after the onset of symptoms (Takeda et al, 1989). All the antihistamines in
general use for control of vertigo also have anticholinergic activity. With
the possible exception of astemizole (Hismanal) in Meniere’s
disease (Turner and Jackson, 1989), antihistamines that do not cross the
blood brain barrier, are not used to control vertigo. Unfortunately, astemizole
does not appear to be generally useful as it is ineffective in preventing motion
sickness (Kohl et al, 1987) and because it has significant potential toxicity.
There is evidence for involvement of several types of histamine receptors. Serafin
and others (1993) reported that histamine increases firing in MVN cells, mediated
through the h3 receptor. h2 receptors are present in guinea pig vestibular nucleus,
but they don’t seem to be relevant to vertigo, and it does not appear that the
therapeutic effects of h2 receptor blockers can be attributed to blockate of
h2 (Timmerman, 1994). h4 receptor agonists appear to cause the same result as
blockade of h3 receptors. Most antihistamines also have calcium
channel blocking effect (according to Timmerman, 1994).
Histamine agonists that act on receptor subtypes are also used for treatment of vertigo (e.g. betahistine). This can sometimes result in a peculiar situation where individuals take both antihistamines and histamine agonists at the same time. When this is done, it would seem most logical to use a peripherally acting antihistamine that does not cross the blood brain barrier, with the hope that the central action will dominate. While in theory, one might attempt to avoid central antihistamine side effects (e.g. drowsiness, weight gain), by combining a mixed anticholinergic/antihistamine such as meclizine with betahistine, we do not know of any evidence one way or the other. We would guess that it does not work.
|Drug||Lowest effective dose||Time constant in the blood||“Low dose” to manage chronic vertigo|
|Lorazepam||0.5||12-18 hours.||0.5 mg twice/day|
|Clonazepam||0.5||30 hours||0.5 mg twice/day|
|Diazepam||2 mg||several, up to 24 hours.||2 mg twice/day|
|Alprazolam||0. 25 mg||8 hours (6-12-15)||Not recommended|
|Chlordiazepate||7.5 mg||10-30 hours||Not recommended|
Benzodiazepines are GABA modulators, acting centrally to suppress vestibular
responses. See this page for a longer discussion. They increase the affinity of chloride channel opening (Soto et al, 2013). There are differential effects across benzodiazepines on Gaba-A receptor subtypes. In small doses, these drugs are extremely useful. Addiction, impaired memory, increased risk of falling, and possibly impaired vestibular compensation are
their main shortcomings.
Lorazepam and klonazepam are particularly useful agents because of their effectiveness and simple kinetics. Addiction, the biggest problem, can usually be avoided by keeping the dose to 0.5 mg BID or less. Note that lorazepam and klonazepam have quite different time constants (i.e. durations of action), with lorazepam being shorter, which makes for some interesting trade-offs. Other problems with benzodiazepines include higher incidence of car accidents (risk x1.5), and hip fractures (risk x 1.8) (Ray, Griffin et al. 1987; Ray, Fought et al. 1992). Fall risk is increased in the elderly by roughly the same proportions.
Similarly, low doses of diazepam (Valium) (2 mg) can be quite effective for dizziness. Clonazepam (Klonopin), is as effective a vestibular suppressant as lorazepam (Ganaca et al, 2002). The author prefers to avoid use of alprazolam (Xanax) for vestibular suppression, because of the potential for a difficult withdrawal syndrome. Long acting benzodiazepines are not helpful for relief of vertigo.
Doses are all those used routinely for adults,
and will generally not be appropriate for children. Pregnancy
category varies from A (controlled human studies have failed to demonstrate
a risk to the fetus) through D (there is positive evidence of human fetal risk,
use only in a life-threatening situation or for a serious disease for which
safer drugs cannot be used or are ineffective.
Drugs that speed gastric emptying, such as metoclopramide
(Reglan) and powdered ginger root may be helpful in managing emesis (Grontved
et al, 1988). Metoclopramide, a dopamine antagonist and a potent central antiemetic,
is ineffective in preventing motion sickness (Kohl, 1987). Domperidone
(Motilium) is an antiemetic that does not cross the blood brain barrier and
thus has less side effects. Although droperidol has been used in the past, it
is no longer recommended.
There is a possible role for new antiemetics which are
a 5-HT3 antagonists (ondansetron, Zofran; granisetron, Kytril) used
in treating the nausea associated with chemotherapy and post-operative nausea
and vomiting. The high cost of these agents presently limits their usefulness
in the treatment of vertigo, but they are reasonable agents to try in situations
where the more usual agents are ineffective or contraindicated. These agents
do not appear to be helpful in preventing motion sickness (Stott et al, 1989).
In theory, these agents might be less effective for vestibular elicited emesis
than agents with other pharmacologic actions.
Mechanisms of effect of antidepressants for dizziness
- Anticholinergic (such as amitriptyline and nortriptyline)
- Antimigraine (such as amitriptyline, nortriptyline or venlafaxine)
- Antidepressant (improved well being)
All antidepressants increase ataxia and many cause
nausea as well as hypotension. Thus one would think that their role would be
limited. However, the ability of antidepressants to manage the psychological
fallout from dizziness is often helpful (Horii, Mitani et al. 2004) Horii, A.,
K. Mitani, et al. (2004). Some antidepressants such as amitriptyline have
strong anticholinergic properties which can be of use in managing dizziness. There are several reports of a positive effect, lacking an explanation (e. g. Grubb et al, 1996)
Calcium channel blockers are the most promising agents
in this group. More detail about these drugs can be found here.
Calcium channel blockers, such as flunarizine and cinnarizine,
are popular antivertiginous agents outside of the U.S. (Rascol et al, 1989).
Flunarizine however is also a dopamine blocker, and cinnarizine an antihistamine. Some calcium channel blockers, such as verapamil, have quite strong constipating
effects, which may be helpful in managing diarrhea caused by vestibular imbalance.
However, calcium channel blockers often have anticholinergic and/or antihistaminic
activity and the relative importance of calcium channel blocking associated
activity for vestibular suppression has not been determined (Rascol et al, 1989).
Another problem is that almost all antihistamines have calcium-entry blocking
capacity and/or calmodulin blocking properties, making it difficult to ascertain
the mechanism of action (Timmerman, 1994).
According to Soto et al (2013), Cinnarizine also blocks pressure sensitive potassium channels, which may provide it with a separate mechanism for treatment of hydrops.
Calcium channel blockers may be effective
in “vestibular Menieres”,
or “benign recurrent vertigo”, as persons with this diagnosis have
a high prevalence of migraine (Rassekh and Harker, 1992), for which calcium channel blockers can be very effective.
According to Soto et al (2013) the most commonly used calcium channel blockers for vertigo are nimodipine, nitrendipine (long lasting) and verapamil. Other long lasting dihydropyridines such as amlodipine, felodipine, nicardipine and nifedipine are seldom used. The author has found daily verapamil to be helpful in a roughly 1/3 of his patients
with classic Menieres, causing amelioration or suppression of attacks as long
as a reasonable dose is taken. This use of verapamil for vertigo has not been
studied or approved in the US. Nimodipine, however, has recently been reported
to be effective as prophylaxis of Menieres. In the US, our experience is that only verapamil is used to any great extent.
Gabapentin is also a calcium channel blocker (it is not a GABA agonist in spite of the name).
Carbonic anhydrase inhibitors such as acetazolamide are commonly used to treat episodic ataxia, and are rarely used for Meniere’s disease. Weak carbonic anhydrase inhibitors such as topiramate and zonisamide have some efficacy in migraine. Most of these are sulfonamides.
A potassium channel blocker, 3-4 DAP (diaminopyridine) as well as its close relative, 4AP, has been reported useful for persons with ataxia and downbeating nystagmus.
This drug is sometimes used for fatigue in MS, as well as for a rare neuromuscular disorder (Eaton Lambert). Side effects include
perioral and/or distal paraesthesia 30-60 minutes after a dose,
difficulty in sleeping. Excessive dosage can lead to seizures. The typical starting dose is 10 mg three times/day. 4-AP is a similar agent that has better CNS absorption. We have had no success with this drug at all in treating suitable patients in our clinical practice, and while we continue to be hopeful. Note that the brand-name version of 4AP is priced about 20 times higher than the compounded version of the same chemical.
A sodium channel blocker, phenytoin (Dilantin),
has also been reported to be protective against motion sickness (Knox
et al, 1994). We have not found this useful.
The author of this review has had no success in limited trials
in patients with severe motion sickness unresponsive to the usual agents. Gabapentin
(Neurontin), carbamazepine (Tegretol) and oxcarbazepine (Trileptal) are also
sometimes successfully used in treatment of vertigo, although their use has
not been studied extensively. Gabapentin has also been successfully used to
suppress certain types of central nystagmus (Stahl et al, 1995). As these agents affect GABA, which is important in vertigo,
an antivertigo effect is reasonable.
The sodium channel blockers carbamazepine and oxcarbazepine are particularly
useful in paroxysmal disorders such as microvascular
compression syndrome, and neuritis of the vestibular nerve. They are also occasionally used for tinnitus. Because the both lower serum sodium, they are also sometimes used for treatment of hydrops (i.e. Meniere’s disease).
have been developed for epilepsy which are glutamate antagonists, but
at this writing, they have not been tried as treatments of vertigo.
Another Gaba agonist, Baclofen (Lioresal) has shown some
promise in reducing vestibular asymmetry. A human trial indicated that it is not useful in speeding up vestibular compensation (de Valc et al, 2009), but nevertheless this agent may have other uses. GABA would be more likely to slow down compensation.
This agent might be suitable for patients with uncompensated vestibular asymmetries.
In our clinical practice, we use Baclofen very rarely.
Dopamine blockers for vertigo:
There are a large assortment of dopamine blockers used for emesis. These drugs may also treat migraine (as they are often effective migraine abortive drugs). In fact, Flunarizine is the dominant migraine prevention drug used in Europe. All are limited by their propensity to cause movement disorders (such as drug induced parkinsonism) as well as others. In our view, these drugs should be “last resort” for treatment of chronic vertigo conditions. We are, for example, against the use of Stugeron (cinnarizine) for any chronic dizzy condition. Flunarizine is a close relative to cinnarizine. These drugs are generally considered acceptable for acute use however.
Whereas the antihistamines used in treating vertigo
are usually centrally acting histamine h2-receptor antagonists, in some parts
of the world an h2+h3-receptor agonist and h4-h5 antagonist, Serc (betahistine),
is used. This is an interesting group
that has been poised to move from the uncertain role category to the
more conventional category for decades. The main problem with it is that rigorous studies proving efficacy are generally are not available, although unrigorous studies abound. According to Timmerman quoting Laurikainen, h2 receptors do not appear
to be important at all in vestibular function and the antivertiginous effects
of antihistamines are mediated either through non-h2 receptors or other effects
of the drugs. Also, the h2 (and h3 effects) are minor. Serc’s
effects might occur through h3 agonism or h4 antagonism (Timmerman, 1994). h4
is an autoreceptor that modulates h2/h3 as well as potentially other neurotransmitter
systems. Recently a 4th histamine receptor (h5) has been identified. h5 antagonists are reported to suppress rat primary vestibular neuron firing (Desmadryl et al, 2012). Also, according to these authors, betahistine does not have a significant effect on the h5 receptor in conventional doses. This may account for the recent suggestions to push the dose up to very high levels (e.g. Strupp et al, 2008).
In the rat brainstem, betahistine produces a slight excitatory response in MVN neurons, and it reduces the excitatory effect of histamine (Soto et al, 2013).
Pragmatically, a betahistine dose of 16 mg twice to three times/day
is usually prescribed, although greater effect is obtained for doses as high
as 48 mg (Strupp,et al. 2008). The rationale for this use is that betahistine is said to increase
circulation to the inner ear (Halmagyi, 1992) or affect vestibular function through activity of h4 or h5 receptors (Kingma et al, 1997; Timmerman, 1994; Desmadryl et al, 2012). It is difficult to see why vasodilation should improve vertigo, as vasodilation/constriction are side effects of many medications that have no effect at all on vertigo (e.g isorbide). At this writing, as h3 agonism would be stimulatory, it appears most likely
that Serc acts through the h4 or h5 receptor.
Serc is approved by the FDA
in the US but only if dispensed through compounding pharmacies. It was categorized, in essence, as a harmless substance. Histamine is
sometimes prescribed as sublingual drops or subcutaneous injections. It is the
author’s opinion that sublingual or subcutaneous histamine is a placebo as it
is rapidly degraded. Nevertheless, in the authors experience, Serc is moderately
effective in suppressing symptoms of Meniere’s disease, for uncertain reasons. Following the pharmacological
discussion above, Serc might be expected to be effective in any peripheral vestibular
disorder, not merely Meniere’s disease.
Opiods often cause constipation, and drugs that cause constipation usually also reduce dizziness. Droperidol (a dopamine blocker) combined with fentanyl (a powerful opiate) was reported to be effective for acute attacks of Meniere’s disease (Soto et al, 2013). Our thought is that these drugs are far too dangerous to use for this purpose, and that there are much easier ways to stop Meniere’s attacks (e.g. lorazepam and ondansetron together).
Steroids for vestibular disorders.
Corticosteroids such as decadron have
been advocated both for treatment of Meniere’s
disease and Vestibular neuritis,
in both cases, in an attempt to reduce the duration of a vertiginous episode.
They are also commonly used for sudden hearing loss. Data concerning efficacy for dizziness is presently conflicted (see here for a review of data). There are many possible mechanisms of efficacy — modulation of compensation (Cameron et al, 1999), reduction of immune responses in the inner ear (see here), reduction of swelling of the vestibular nerve (Strupp et al, 2004), reduction of emesis (Wattwil et al, 2003), increased activity promoting better recovery through a general effect on the sensation of wellbeing. (See here for the references).
Steroids are commonly used to treat acute flareups of Meniere’s disease. The author will occasionally use a few
day course of decadron (4 mg qd) or a medrol dose pack, when faced with a severe and unremitting vertigo
attributed to Menieres disease. The author routinely uses steroids in acute vestibular neuritis, when there is no serious coincident medical disorder (such as diabetes). All steroids are pregnancy category C, but they
are generally felt to be safe during the third trimester.
More about oral steroids can be found here, and steroids injected through the ear drum, here.
These drugs increase norepinephrine. Examples include ephedrine and
the amphetamines. Sympathomimetics may increase alertness and thereby counterbalance
the sedative effects of vestibular suppressants. Sympathomimetics also may increase
compensation. However, if used for this purpose, the combination of a vestibular
suppressant with a drug targeted to increase compensation seems somewhat illogical.
Amphetamines are little used because of their addiction potential. Sympathomimetics
are generally pregnancy category C.
Dopamine agonists reduce firing rate in the frog hair cells and also reduces resposne to glutamine (the excitatory transmitter) (Soto et al, 2013). On the other hand, dopamine antagonists are uncommonly used to treat vertigo (e.g. Droperidol, phenothiazines), suggesting that the net effect is against using dopamine agonists.
This medication is marketed and largely
used in France (Rascol et al, 1995). It is claimed to exert a rapid antivertiginous effect
when administered intravenously in humans and also to act as a vestibular suppressant. It
is not used in the US for vertigo. The evidence for it working is not the best.
This extract is widely used in
France, but its efficacy is in question (Rascol et al, 1995). It has been reported
to suppress vertigo and to enhance vestibular compensation in animals. See here
for more information.
Selective ACH antagonists.
The ACH receptor has numerous
subtypes, and it would seem reasonable that a selective antagonist to the M2 receptor
might cause vestibular suppression without many of the untoward side effects of the more
general anti-ACH agents. Unfortunately, little research has been pursued in this direction
at the present time.
Alternative medicine agents.
Cocculus is advocated
for the temporary relief of lightheadedness. For-HEEL and Vertigo-HEEL is also
suggested for vertigo. NAC is also sometimes recommended for hearing disorders. See here
for more about these agents.
N-acetyl Cysteine (NAC) is another agent suggested for dizziness or tinnitus. See this page.
Various individual agents, best avoided.
This drug, approved by the FDA for smoking cessation, has recently been reported useful for treatment of cerebellar ataxia (Zesiewicz et al, 2009). It is extremely surprising to find an agent that will ameliorate disorders caused by genetic damage to neurons. It is also disturbing that the number of individuals in the trial (7) was exactly the same as the number of authors on the study. In other words, it would seem to us that if this drug was effective, the number of subjects should be larger as patients with cerebellar disorders are common. We are frankly very dubious. We have never encountered a patient who responded to this mediation (who wasn’t attempting to stop smoking).
This drugs is a medication developed for angina (cardiac disturbance). It has been reported useful in diverse disorders (Soto et al, 2013), including Meniere’s disease. The evidence for this drug working is presently weak. For example, it is reported to be “as effective” as betahistine. Trimetazidine can also induce a myriad of CNS disorders, largely similar to those produced by dopamine antigonists (i.e. similar to haloperidol — Haldol).
This drug is mainly a glutamate blocker (NMDA), and thus might be a vestibular suppressant. It was approved in the US for prevention of progression of Alzheimer’s disease. It also is reported to act on 5HT3, D2, and various cholinergic receptors (Soto et al, 2013). We have never encountered a dizzy patient who responded to memantine. We have also never encountered a patient whose pendular nystagmus responded to memantine. This is hardly suprising as it is a low-affinitive NMDA antagonist. A similar drug is caroverine, that is a glutamate AMPA receptor antagonist.
Hallucinogenic NMDA drugs (antagonists)
These include MK-01, phencyclidine (PCP, “angel dust”), and ketamine (“special K”) among others. Of course, side effects and abuse are a problem. Ketamine produces a general “lack of responsive awareness”, as well as dizziness (Soto et al, 2013).
Antihistamines, 1st Generation, Anxiolytics, Benzodiazepines, Phenothiazine Derivatives, Alpha/Beta Adrenergic Agonists, Anticholinergic Agents
Hesham M Samy, MD, PhD Associate Professor of Audiovestibular Medicine, Minia Unversity, Egypt
Hesham M Samy, MD, PhD is a member of the following medical societies: American Academy of Audiology, American Auditory Society, Association for Research in Otolaryngology, Egyptian Society of Otorhinolaryngology
Disclosure: Nothing to disclose.
Mohamed A Hamid, MD, PhD Founder and Medical Director, The Cleveland Hearing and Balance Center; Clinical and Adjunct Professor of ENT, Case-MetroHealth, Medical College of Virginia, and Ain Shams University, Egypt
Mohamed A Hamid, MD, PhD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Otological Society, American Neurotology Society
Disclosure: Nothing to disclose.
Marc Friedman, DO, FAAN Consultant in Otoneurology, The Cleveland Hearing and Balance Center
Disclosure: Nothing to disclose.
Specialty Editor Board
Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM Adjunct Associate Professor of Neurology, University of Missouri-Columbia School of Medicine; Medical Director of St Mary’s Stroke Program, SSM Neurosciences Institute, SSM Health
Niranjan N Singh, MBBS, MD, DM, FAHS, FAANEM is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Headache Society
Disclosure: Nothing to disclose.
Robert A Egan, MD NW Neuro-Ophthalmology
Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, Oregon Medical Association
Disclosure: Received honoraria from Biogen Idec and Genentech for participation on Advisory Boards.
Marc Friedman, DO Chief of Neurology, Parma Hospital, Consultant, Department of Neurology-Neurotology, Cleveland Hearing and Balance Center
Disclosure: Nothing to disclose.
Spiros Manolidis, MD Associate Professor of Otolaryngology and Neurological Surgery, Columbia University
Spiros Manolidis, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Head and Neck Society, American Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, Society of University Otolaryngologists-Head and Neck Surgeons, and Texas Medical Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Reference Salary Employment
Vertigo | Causes, and Medicines
What is vertigo?
Vertigo is a type of dizziness that can last just for a short period of time (minutes) or that can last for hours or even days. People who have vertigo have a false feeling of their surroundings moving or spinning. This is usually accompanied by a feeling of sickness (nausea) and a loss of balance. The condition can also cause someone with the condition to be sick (vomit). Vertigo is a symptom and not a condition in itself. In most cases there is a medical condition that causes vertigo. However, sometimes the cause is unknown.
The most common cause of vertigo is a problem with the inner part of the ear – for example, an infection or inflammation. When we move our head, the inner part of the ear tells us where our head is. It does this by sending signals to the brain and this helps us to keep our balance. If there are problems with the inner part of the ear then this causes us to feel sick (nausea) and dizzy.
Other conditions that can affect the inner ear and cause vertigo include Ménière’s disease, motion sickness and toxicity of the ear caused by medicines. A common cause of vertigo in older people is benign paroxysmal positional vertigo. This causes intense dizziness (short episodes of vertigo) when you move your head in certain directions. It it thought to be caused by tiny fragments of debris in the inner ear.
Less commonly, vertigo may be caused by conditions that make changes to certain parts of the brain – for example:
The treatment of vertigo depends on what has caused it. For example, if you have an ear infection your doctor may prescribe an antibiotic. For other causes of vertigo your doctor may give you special exercises to do. The rest of this leaflet only discusses medicines that help to ease the symptoms of dizziness and nausea caused by vertigo. There are separate leaflets called Benign Paroxysmal Positional Vertigo, Ménière’s Disease, Vestibular Neuritis and Labyrinthitis, Dizziness and Migraine.
Note: vertigo is sometimes referred to as a ‘fear of heights’ – this is not correct. The right term for the fear of heights is acrophobia.
What are medicines for vertigo and how do they work?
A number of medicines can be prescribed to help with the symptoms of vertigo. They include prochlorperazine or antihistamines such as cinnarizine, cyclizine or promethazine. These medicines are the same ones that are used to help treat any feeling of sickness (nausea) and motion sickness. They work by blocking certain chemicals in the brain. Prochlorperazine blocks a chemical called dopamine; this helps with severe sickness. Antihistamines block histamine, which helps with mild sickness and being sick (vomiting) as well as vertigo. Betahistine is an antihistamine that may be prescribed for patients with Ménière’s disease, to prevent attacks from occurring. It is thought that this medicine improves the blood flow around the ear.
These medicines come in various brand names and are available as tablets, capsules, liquids and injections. Some are available as tablets that dissolve between the upper gum and lip (sublingual tablets).
How well do these medicines work?
There are no good studies that tell us how well these medicines work. However, they have been prescribed to treat vertigo for many years.
Which medicine is usually prescribed?
The choice of medicine depends on what is causing your vertigo and how severe your symptoms are. If you have a severe feeling of sickness (nausea), your doctor may prescribe prochlorperazine. The advantage of this medicine is that it is available as an injection or as a tablet to dissolve between the upper gum and lip (a sublingual tablet). It may be more suitable for people who are very sick and being sick (vomiting).
If you have mild nausea, your doctor may prescribe an antihistamine such as cinnarizine, cyclizine or promethazine. These will also help to treat dizziness.
What is the usual length of treatment?
Medicines to treat vertigo and sickness are usually only taken for a short time – normally from 3 to 14 days. If you have vertigo frequently, your doctor may prescribe a short supply of these medicines to keep at home, to use when you have another attack.
What about side-effects?
It is not possible to list all the possible side-effects of each of these medicines in this leaflet. However, as with all medicines, there are a number of side-effects that have been reported. If you want more information specific to your medicine, see the information leaflet that came with your medicine.
Most side-effects are not serious and each person may react differently to these medicines. Common side-effects include drowsiness, constipation, headaches, tiredness, trouble with sleeping (insomnia) and indigestion. Prochlorperazine can cause muscle twitching of the shoulders, face and neck. This usually goes away once this medicine is stopped.
Who cannot take medicines for vertigo?
There are very few people who cannot take a medicine for vertigo. If for some reason one medicine has caused a side-effect or there is a reason you cannot take one, your doctor can choose a different type of medicine that will suit you.
Can I buy medicines for vertigo?
You can buy cinnarizine from your pharmacy but the pharmacist can only sell it to people who have motion sickness.
How to use the Yellow Card Scheme
If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at www.mhra.gov.uk/yellowcard.
The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:
- The side-effect.
- The name of the medicine which you think caused it.
- The person who had the side-effect.
- Your contact details as the reporter of the side-effect.
It is helpful if you have your medication – and/or the leaflet that came with it – with you while you fill out the report.
What is the treatment for labyrinthitis?
Treating the symptoms associated with labyrinthitis
The following medication can be prescribed to help relieve the symptoms of an inner ear infection:
- Antihistamines – desloratadine (Clarinex), or over-the-counter options such as loratadine (Claritin), diphenhydramine (Benadryl), or fexofenadine (Allegra).
- Meclizine (Antivert) which helps to reduce nausea and dizziness.
- Diazepam as a sedative.
- Prednisone as a corticosteroid (these are used to treat inflammation).
- Motion sickness medication to aid in the treatment of loss of balance and vertigo.
- Antibiotics will only be prescribed if you have a bacterial infection in the respiratory tract, or if the labyrinthitis is bacterial as antibiotics are not effective in the treatment of viral infections. Blood cultures and swabs of the fluid, if there is fluid available, will detect which bacteria is present and then an antibiotic will be prescribed.
Treating vertigo associated with an inner ear infection
- Do not move in sudden or quick movements.
- It is better to be in low lighting as this can help if you are feeling dizzy as bright lights are often deemed overwhelming when experiencing vertigo.
- If you are lying in bed and experience vertigo, try to keep your head still and sit up slowly.
- If you are walking and experience vertigo, try to find something to lean on or slowly sit down until it subsides.
PLEASE NOTE: It is not safe to drive if you are experiencing vertigo on a regular basis.
Home remedies for treating an inner ear infection
- Try to rest in a position that is comfortable for the first few days.
- Keep hydrated and drink a lot of water.
- Try to reduce your sodium and sugar intake as this can affect your vertigo as these foods are known to spike blood sugar levels.
- Avoid chocolate, alcohol and caffeine.
- Do not smoke cigarettes as these can make you feel lightheaded.
Treatment for chronic labyrinthitis
Some people may suffer from vertigo and dizziness associated with an inner ear infection for a number of months or years, experts and doctors will typically refer to this as chronic labyrinthitis (i.e. long-term labyrinthitis).
The symptoms of chronic labyrinthitis are not usually experienced as severely as when one is first diagnosed with an inner ear infection and vertigo and dizziness tend to lessen over time. However, these mild symptoms associated with an inner ear infection may persist and adversely impact one’s daily activities and quality of life.
In order for those suffering from chronic labyrinthitis to seek some form of relief from long-term symptoms, a form of treatment known as VRT (vestibular rehabilitation therapy) is often recommended by doctors.
VRT (vestibular rehabilitation therapy)
This exercise-based form of treatment is designed to help ease the symptoms of a chronic inner ear infection, particularly those of vertigo and dizziness, the exercise program does this by promoting vestibular (i.e. relating to the inner ear) adaptation, as well as substitution. Simply put, VRT aids in retraining the nervous system and brain in order to compensate for any abnormal symptoms and signs stemming from the vestibular system.
VRT is typically supervised by a specialist such as a physiotherapist. A physiotherapist is a qualified expert in treating injury, disease or deformity through utilising physical methods such as exercise, massage and even heat treatment. He or she will make use of a range of different exercises designed to aid in the below ways:
- Improvement of hand-eye co-ordination – enhancing the stability of one’s gaze
- Simulation of dizziness in order to allow the brain to adjust to the specific disruptive signals that are sent to it from the vestibular system and train it to ignore these signals.
- Improvement of walking ability and balance
- Improvement of fitness and strength
Diphenhydramine (Systemic) | Memorial Sloan Kettering Cancer Center
This document, provided by Lexicomp ® , contains all the information you need to know about the drug, including the indications, route of administration, side effects and when you should contact your healthcare provider.
Trade names: USA
Aler-Dryl [OTC]; Allergy Childrens [OTC]; Allergy Relief Childrens [OTC]; Allergy Relief [OTC]; Anti-Hist Allergy [OTC]; Aurodryl Allergy Childrens [OTC]; Banophen [OTC]; Benadryl Allergy Childrens [OTC]; Benadryl Allergy Ultratabs [OTC]; Benadryl Allergy [OTC]; Complete Allergy Medication [OTC] [DSC]; Complete Allergy Relief [OTC]; Di-Phen; Diphen; Diphen [OTC]; Diphenhist [OTC]; Genahist [OTC]; Geri-Dryl [OTC]; GoodSense Allergy Relief [OTC]; GoodSense Sleep Aid [OTC]; M-Dryl [OTC]; Naramin [OTC]; Nighttime Sleep Aid [OTC]; Nytol Maximum Strength [OTC] [DSC]; Nytol [OTC] [DSC]; Ormir [OTC] [DSC]; PediaCare Childrens Allergy [OTC]; Pharbedryl [OTC]; Q-Dryl [OTC] [DSC]; Scot-Tussin Allergy Relief [OTC] [DSC]; Siladryl Allergy [OTC]; Silphen Cough [OTC] [DSC]; Simply Sleep [OTC]; Sleep Tabs [OTC]; Sominex [OTC] [DSC]; Tetra-Formula Nighttime Sleep [OTC]; Total Allergy Medicine [OTC]; Total Allergy [OTC]; Triaminic Cough / Runny Nose [OTC] [DSC]; ZzzQuil [OTC]
Trade names: Canada
What is this drug used for?
- Used to relieve coughs.
- Used to relieve allergy symptoms.
- It is used for motion sickness.
- Used to treat symptoms such as Parkinson’s disease caused by other health problems.
- Used to treat sleep disorders.
What should I tell my doctor BEFORE taking this drug?
- If you are allergic to this drug, any of its ingredients, other drugs, foods or substances. Tell your doctor about your allergy and how it manifested itself.
- If the patient is a premature baby or newborn. Do not give this form of the drug to a premature baby or newborn.
This list of drugs and diseases that may be adversely associated with this drug is not exhaustive.
Tell your doctor and pharmacist about all the medicines you take (both prescription and over-the-counter, natural products and vitamins) and your health problems.You need to make sure that this drug is safe for your medical conditions and in combination with other drugs you are already taking. Do not start or stop taking any drug or change the dosage without your doctor’s approval.
What do I need to know or do while taking this drug?
All forms of issue:
- Tell all healthcare providers that you are taking this drug.These are doctors, nurses, pharmacists and dentists.
- Do not take the drug in higher doses than the doctor prescribed. Taking more than the prescribed amount of the drug increases the risk of serious side effects.
- Do not take this drug for longer than your doctor prescribed.
- Avoid driving and other activities that require increased attention until you see how this drug affects you.
- Do not use with other preparations containing diphenhydramine.
- Avoid drinking alcohol while taking this drug.
- Consult your doctor before using marijuana, other forms of cannabis, prescription or over-the-counter drugs that may slow you down.
- If you are 60 years of age or older, use this drug with caution. You may have more side effects.
- If the patient is a child, use this medication with caution.In children, the risk of some side effects may be higher.
- Tell your doctor if you are pregnant, planning to become pregnant, or breastfeeding. The benefits and risks for you and your child will need to be discussed.
Drugs for the treatment of sleep disorders:
- This medicinal product is not intended for use in children under 12 years of age. However, your doctor may conclude that the benefits of using this drug outweigh the risks associated with it.If your child has received this drug, ask your doctor about the benefits and risks. If you have any questions about how to give this drug to your child, talk to your doctor.
All other dosage forms:
- Various brands of this drug may be intended for use in children of different ages. Talk to your doctor before giving this drug to a child.
- Do not use for sleep disorders in children.Consult your doctor.
What side effects should I report to my doctor immediately?
WARNING. In rare cases, some people with this drug can have serious and sometimes deadly side effects. Call your healthcare professional or get medical attention right away if you have any of the following signs or symptoms, which may be associated with serious side effects:
- Signs of an allergic reaction such as rash, hives, itching, reddened and swollen skin with blistering or scaling, possibly associated with fever, wheezing or wheezing, tightness in the chest or throat, difficulty breathing, swallowing or speaking, unusual hoarseness, swelling in the mouth, face, lips, tongue, or throat.
- Severe dizziness or fainting.
- Balance change.
- Decreased attention.
What are some other side effects of this drug?
Any medicine can have side effects. However, many people have little or no side effects. Call your doctor or get medical help if these or any other side effects bother you or do not go away:
- Feeling dizzy or drowsy.
- Thickening of the nasal or pharyngeal mucosa.
- Nervous tension and agitation.
- Nausea or vomiting.
This list of potential side effects is not exhaustive. If you have any questions about side effects, please contact your doctor. Talk to your doctor about side effects.
You can report side effects to the National Health Office.
You can report side effects to the FDA at 1-800-332-1088.You can also report side effects at https://www.fda.gov/medwatch.
What is the best way to take this drug?
Use this drug as directed by your healthcare practitioner. Read all the information provided to you. Follow all instructions strictly.
All oral preparations:
- Take with or without food. Take with food if the medicine causes nausea.
Drugs for the treatment of sleep disorders:
- Take this drug before bed.
Chewable and Orally Disintegrating Tablets:
- Should be chewed thoroughly or allowed to dissolve in the mouth.
- If you have phenylketonuria, talk to your doctor. Some foods contain phenylalanine.
- Place the oral strip on your tongue and let it dissolve.
All liquid preparations:
- Measure liquid doses with care.Use the dispenser that comes with the medicine. If a dispenser is not included in the package, ask your pharmacist for a dosing product for this drug.
- If you have phenylketonuria, talk to your doctor. Some foods contain phenylalanine.
- Shake well before use.
- For intramuscular or intravenous injection.
- This drug may cause tissue damage if it is injected into the skin or into adipose tissue under the skin. Consult your doctor.
What should I do if a dose of a drug is missed?
Drugs for the treatment of sleep disorders:
- This drug should be taken as needed. Do not take this medicine more often than prescribed by your doctor.
All other oral preparations:
- If you are taking this medication regularly, take the missed dose as soon as you can.
- If it is time for your next dose, do not take the missed dose and then return to your normal schedule.
- Do not take 2 doses at the same time or an additional dose.
- In most cases, this drug is used as needed. Do not take this medicine more often than prescribed by your doctor.
- Call your doctor for further instructions.
How do I store and / or discard this drug?
All oral preparations:
- Store at room temperature, protected from light.Store in a dry place. Do not store in the bathroom.
All liquid preparations:
- Do not freeze.
- Throw away any unused portions after 8 weeks.
- If you need to store this drug at home, ask your doctor, nurse, or pharmacist for information about how it is stored.
All forms of issue:
- Store all medicines in a safe place.Keep all medicines out of the reach of children and pets.
- Dispose of unused or expired drugs. Do not empty into toilet or drain unless directed to do so. If you have any questions about the disposal of your medicinal products, consult your pharmacist. Your area may have drug recycling programs.
General information on medicinal products
- If your health does not improve or even worsens, see your doctor.
- You should not give your medicine to anyone and take other people’s medicines.
- Some medicines may have different patient information sheets. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
- Some medicines may have different patient information sheets. Check with your pharmacist. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other healthcare professional.
- If you think there has been an overdose of a drug, call a Poison Control Center immediately or seek medical attention. Be prepared to tell or show which drug you took, how much and when it happened.
Use of information by consumer and limitation of liability
This information should not be used to make decisions about taking this or any other drug. Only the attending physician has the necessary knowledge and experience to make decisions about which drugs are appropriate for a particular patient.This information does not guarantee that the drug is safe, effective, or approved for the treatment of any disease or specific patient. Here are only brief general information about this drug. It does NOT contain all available information on the possible use of the drug with instructions for use, warnings, precautions, information about interactions, side effects and risks that may be associated with this drug. This information should not be construed as a treatment guide and does not replace information provided to you by your healthcare professional.Please consult your doctor for complete information on the possible risks and benefits of taking this drug.
© UpToDate, Inc. and its affiliates and / or licensors, 2021. All rights reserved.
Benadryl – Benadryl – xcv.wiki
Benadryl is a brand name for a variety of antihistamines used to stop allergies, the content of which varies from country to country, but includes some or no combination of diphenhydramine, acrivastine and cetirizine.
It is sold by Johnson & Johnson. Benadryl is used to relieve allergy symptoms such as sneezing, itching, runny nose, rashes, and hives. Some forms of Benadryl should be taken orally, and some creams and gels should be applied to the skin. Common side effects of the drug include drowsiness, dizziness, dry mouth and throat, confusion, and blurred vision.
In the USA and Canada, the active ingredient is diphenhydramine.In the United Kingdom, the active ingredients in Benadryl are the antihistamines acrivastine or cetirizine. Benadryl is also marketed as a cough medicine in Australia and New Zealand that contains diphenhydramine as well as the antitussive dextromethorphan or expectorant guaifenesin.
Types of Benadryl
There are many different forms of Benadryl found in different countries. There are several versions of Benadryl for allergies in the United States and Canada, some of which can be taken by mouth and some as a local analgesic.In Australia, New Zealand and India, Benadryl is known as a cough liquid.
Benadryl Allergy is the name of a Benadryl product found in the United States and Canada. It is an antihistamine used to relieve allergies. Its active ingredient is diphenhydramine, a first generation antihistamine. First generation antihistamines are the oldest group of antihistamines and include diphenhydramine, which is found in Benadryl.It is known to have a calming effect, which is why sleepiness is a common side effect. It is an oral medication that should be taken by mouth to relieve symptoms of allergies, hay fever, and colds. It can also be used to relieve allergies such as itching, sneezing, runny nose, rashes, and hives.
Benadryl tablets for allergies
Benadryl Allergy for Children is also available. It comes in liquid form and can be used to quickly and effectively relieve allergies such as sneezing, itching, runny nose, itchy eyes, and hives.
Benadryl Allergy is widely used by adults as a sleeping pill. Although not marketed as an over-the-counter sleeping pill, most versions of Benadryl contain diphenhydramine, a drug with sedative properties. Diphenhydramine (Benadryl) has also been used by parents to help improve their infant’s sleep habits, however this has been met with criticism as to whether it is appropriate to do so.
Benadryl for allergy relief
Benadryl can be found in the United Kingdom as a remedy for Benadryl allergies.The main ingredient in this medicine is acrivastine. Acrivastine is a non-drowsy antihistamine used to treat allergies. May help with hay fever, hives, insect bites, conjunctivitis, and eczema. Benadryl Allergy Relief contains 8 mg of acrivastine in each capsule. It should be taken orally.
Benadryl Allergy Relief Plus Decongestant can also be found in the United Kingdom. It is used to relieve sinuses, congestion and runny nose, itchy eyes, and sneezing.This version contains acrivastine and pseudoephedrine as active ingredients. Pseudoephedrine is a decongestant used to relieve nasal congestion. Benadryl Allergy Relief Plus Decongestant contains 8 mg acrivastine and 60 mg pseudoephedrine per capsule and must be taken orally.
Benadryl can also be found in topical form including gels and creams. Benadryl Itch Stop Cream is a topical cream used to temporarily relieve itching from allergies, hives, or even some insect bites.It can be found in the USA and Canada. This topical medicine contains 2% diphenhydramine hydrochloride and 1% zinc acetate. This medication is for topical use only, not for oral administration.
Benadryl cough syrup
Cough syrup in a medicine measuring cup
Benadryl is available in Australia and New Zealand as a cough syrup. Should not be confused with Benadryl for allergies. There are several forms of cough syrup on the market to treat different types of coughs such as dry, ticklish coughs, chest coughs, and cough with nasal congestion.Cough fluids for children are also available.
Benadryl Honor Forte is used to relieve severe chest cough and chest congestion. The main ingredients found are guaifenesin and bromhexine hydrochloride. It should be taken by mouth to relieve cough and chest congestion from a cold. Benadryl Dry, Tickly Cough Liquid is a cough medicine found in Australia. It is used to temporarily relieve irritating coughs. Folkodin is the main ingredient in this cough liquid.This medication must be taken by mouth and may cause drowsiness.
Benadryl can also be found in India in the form of cough liquid as well as cough drops. Benadryl Cough Syrup contains diphenhydramine, ammonium chloride and citrate as main ingredients. It is used to relieve coughs and colds, and soothes the throat.
Drowsiness is a common side effect of taking Benadryl containing diphenhydramine.Other common side effects may include dry mouth and throat. Symptoms such as confusion and blurred vision may also occur. Other side effects from taking Benadryl include headache and dizziness.
Diphenhydramine is a first generation antihistamine and anticholinergic drug. Anticholinergics block the action of acetylcholine, a central nervous system neurotransmitter. Research shows that long-term use of anticholinergics is associated with an increased risk of dementia in older adults.Long-term use of Benadryl can also lead to constipation and confusion.
Benadryl containing diphenhydramine may interact with alcohol as both are central nervous system (CNS) depressants. Side effects such as drowsiness and dizziness may worsen when alcohol is taken with diphenhydramine. Mixing diphenhydramine with alcohol can also increase the likelihood of unconsciousness due to sedatives.This combination can also lead to impaired motor skills and decreased focus. Driving, operating machinery, or any other activity that requires full concentration and consciousness is not recommended as these effects persist.
Benadryl may interact with other medications such as antidepressants, sleeping pills, muscle relaxants, and other antihistamines. It is important to consult a professional before taking Benadryl with any other medications, vitamins or herbal products.
In 1940, diphenhydramine was discovered by George Riveschl while he was working as a chemical engineer at the University of Cincinnati, where he was conducting research on muscle relaxants.
In 1946, Benadryl was approved by the Food and Drug Administration (FDA) for prescription use. In the 1980s, it was approved as an over-the-counter drug.
Benadryl was marketed by Pfizer Consumer Healthcare (originally Warner-Lambert) until 2007.
On January 15, 2010, McNeil Consumer Healthcare, a subsidiary of Johnson & Johnson, recalled five batches of Benadryl due to an unusual odor associated with the chemical 2,4,6-tribromoanisole.
In April 2010, more than four million packages of Benadryl Children’s Allergy Tablets were recalled after it was discovered that they may contain a higher concentration of active ingredients than indicated on the label, as well as inactive ingredients that do not meet internal testing requirements.
Change of packaging Benadryl for topical application
In 2010, after the FDA reported more than a hundred cases of mistaken swallowing by mouth, the Benadryl Itch Stopping Gel packaging was changed to include a new warning (“for use only on the skin “) and a sticker. was added as an additional precaution.
Society and culture
Diphenhydramine is a common side effect of drowsiness or drowsiness.Because of these sedative properties, Benadryl is often used as a sleeping pill in people with insomnia. A study published in the American Journal of Geriatric Psychiatry , found that about one in three adults between the ages of 65 and 80 sometimes use an over-the-counter medication, such as Benadryl, to improve sleep. In 2017, the American Academy of Sleep Medicine discouraged the use of over-the-counter antihistamines as sleeping pills for the treatment of chronic insomnia.Dr. Suzanne Bertish of Harvard Medical School said that using antihistamines as sleeping pills can cause drowsiness during the day, lethargy and falls.
Recreational use and the Benadryl problem
In May 2020, Cook Children’s Medical Center in Fort Worth, Texas, reported that 3 teens were hospitalized as a result of an overdose of diphenhydramine. They claimed that the teens received information on how to abuse Benadryl from the social media app TikTok.In August of that year, an Oklahoma teenager died of a Benadryl overdose. After a later deleted Facebook post from a member of the teen’s family claimed the death was due to the Benadryl Challenge, news outlets raised the dangers of the alleged social media trend. This prompted the FDA to issue a Danger Statement for high doses of diphenhydramine.
In the UK, a 2009 advertisement for Benadryl Allergy Relief promotes the use of this drug to combat allergies.The campaign aims to “win the war against allergies” such as allergies to seasonal allergens such as pollen. The ad claims Benadryl Allergy Relief is “the fastest-acting, over-the-counter allergy relief capsule.” There are also other Benadryl commercials promoting its use against allergies. In an undated advertisement posted on Youtube, the advertisement promoted the use of Benadryl against pollen with the phrase “when allergies occur, hit back with Benadryl”.
In the 2009 Baby Benadryl ad, the campaign focuses on the use of Baby Benadryl for children to get rid of allergies so that they can continue their activities throughout the day. The ad shows the child sneezing throughout the video, performing various actions. He promotes the use of Baby Benadryl to relieve sneezing, runny nose and itchy eyes and states that “it works when they need it most.” Likewise, in 2008, there is an ad for Benadryl that also promotes the use of antihistamine to relieve allergies when it is needed most, as it says “you can’t stop life.”
Benadryl is sold over the counter in most countries. Benadryl can be found in several countries including the United States, Canada, United Kingdom, Australia, New Zealand, India, Indonesia, and the Philippines.
Benadryl is available as an oral tablet and oral liquid. Some types of Benadryl, such as Benadryl Itch Stopping Cream and Gels, are designed to be applied to the skin, not internally.
90,000 Benadryl (diphenhydramine) side effects, warnings, uses
- Generic Name: Diphenhydramine
- Brand Name: Benadryl
Benadryl Side Effects Center
Medical Editor: John P.Cunya, DO, FACOEP
What is Benadryl?
Benadryl (diphenhydramine) is an antihistamine used to treat allergies, urticaria, insomnia, motion sickness, and mild cases of parkinsonism. Benadryl is available in generic and over-the-counter (OTC) form.
What are the side effects of Benadryl?
Common Benadryl side effects include:
- poor coordination,
- dry mouth / nose / sore throat,
- difficulty urinating or an enlarged prostate,
- blurred vision,
- double vision,
- loss of appetite,
- headache, or
Dosage for Benadryl
Typical Benadryl dosage is 25-50 mg every 4-6 hours.
What medications, substances or additives interact with Benadryl?
Benadryl may interact with monoamine oxidase inhibitors (MAOIs), other over-the-counter medicines for coughs, colds, allergies, or insomnia, medicines for anxiety or sleep, antidepressants, or any other medicine that makes you drowsy, drowsy, or relaxed.Tell your doctor about all medications and supplements you are taking.
Benadryl during pregnancy and lactation
Benadryl has not been adequately evaluated in pregnant women. Benadryl is excreted in breast milk. Because of the risk of stimulation and seizures in infants, especially newborns and premature babies, breastfeeding mothers should not use antihistamines.
Our Benadryl Side Effects Center provides a comprehensive overview of the available drug information about the potential side effects of this drug.
This is not a complete list of side effects and they may arise. Ask your doctor about side effects. You can report side effects to the FDA by calling 1-800-FDA-1088.
lexapro side effects in women
Benadryl Consumer Information
Get emergency medical help if you have signs of an allergic reaction : hives; labored breathing; swelling of the face, lips, tongue, or throat.
Stop using diphenhydramine and call your doctor at once if you have:
- heart palpitations or fluttering in your chest;
- Painful or difficult urination;
- little or no urination;
- confusion, feeling like you might pass out or
- tightness in the neck or jaw, uncontrolled movement of the tongue.
Common side effects may include:
- dizziness, drowsiness, lack of coordination;
- dry mouth, nose, or throat;
- constipation, indigestion;
- dry eyes, blurred vision; or
- daytime sleepiness or “hangover” after overnight consumption.
This is not a complete list of side effects and they may arise. Ask your doctor about side effects. You can report side effects to the FDA by calling 1-800-FDA-1088.
Read all detailed patient monograph for Benadryl (diphenhydramine)
Learn More ‘Benadryl Professional Information
Using this product:
- may experience noticeable drowsiness
- avoid alcohol, sedatives
- and tranquilizers can increase drowsiness
- excitability may occur, especially in children
- Be careful when driving or operating machinery
Read all FDA prescribing information for Benadryl (diphenhydramine)
Read more ‘Related resources on Benadryl
- Allergy (allergy)
- Drug side effects
- Urticaria (urticaria and angioedema)
- Itching (itching or itching)
- Parkinson’s disease
- Che weaving (ticks)
- Sleep disturbances (how to get a good night’s sleep)
Read Benadryl User Reviews »
Benadryl Patient Information is provided by Cerner Multum, Inc.and Benadryl consumer information is provided by First Databank, Inc., used under license and subject to their respective copyrights.
90,000 Insect Bite: Local Reaction
You have been bitten or stung by an insect. The poison or fluid from the insect’s body causes a reaction at the site of the bite. Redness, itching, and swelling are common. This reaction usually goes away after a few hours or days. After 1-3 days, the bite site may become infected, so watch for the signs of infection described below.Sometimes it is difficult to distinguish a local reaction to an insect bite from an early infection, so antibiotics may be prescribed.
If you experience itching, avoid anything that could heat your skin (hot showers or baths, direct sunlight), as heat will increase itching.
Ice pack (a plastic ice bag wrapped in a towel) relieves itching and redness locally. Itching can be relieved with Lanacaine cream or Solarcaine spray (or other products containing benzocaine).
Oral Benadryl (diphenhydramine) is an antihistamine available in pharmacies and grocery stores. Unless another antihistamine is prescribed, Benadryl can be used to relieve itching on large areas of skin. Take the drug in smaller doses during the daytime, and in larger doses before bedtime, as it makes you drowsy. [NOTE. Benadryl is not recommended for people with glaucoma or for men who have difficulty urinating due to an enlarged prostate gland.] Claritin (loratadine) is an antihistamine that causes less drowsiness and is therefore suitable for daytime use.
If the doctor has prescribed ANTIBIOTICS in tablets, be sure to take the full course.
Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) can be taken to relieve pain if no other pain relievers have been prescribed. [ NOTE . If you have chronic liver or kidney disease, or have a history of stomach ulcers or bleeding in the gastrointestinal tract, consult your doctor before taking these drugs.]
Preventing Bite Reactions In the Future
Subsequent reactions can be more severe, so try to avoid situations where you might be bitten by an insect.
Remember that bees live in trees. Wasps and hornets usually nest in the ground, trees, or eaves.
If you are bitten by a bee, a sting will remain in your skin. After a wasp bite, the sting of the hornets does not remain in the skin. Leave the insect nest immediately.A bee sting releases a substance that attracts other bees. Once back in a safe place, remove the sting as soon as possible.
After any bite you can apply ice and take Benadryl or another antihistamine. If any of the troubling symptoms listed below appear, seek immediate help.
If the risk of a new bite is high, or if you experience dizziness, fainting, difficulty breathing or swallowing after a bite, consult your doctor about using the Insect Allergy Kit.
with your doctor or facility within two days if symptoms do not improve.
Get Immediate Medical Assistance
for any of the following:
spread of itching, redness, or swelling;
appearance or increase of swelling of the face, eyelids, lips, mouth, pharynx or tongue;
difficulty swallowing or breathing;
dizziness, weakness, or fainting;
signs of infection:
worsening pain or swelling;
At 100.4єF (38єC) or higher, or as recommended by a healthcare practitioner;
Leakage of colored fluid from the wound.
Russia will ban the challenge on TikTok: all because of the drug
In Russia, some videos on TikTok will be blocked. This applies to videos with the hashtag #benadryl. In fact, this inscription is not as harmless as it seems. The authors of the videos urge people to take the drug for allergies in large quantities to cause hallucinations.We are talking about a challenge in which you do not need to participate.
Roskomnadzor will be responsible for blocking content on the TikTok social network in Russia. This happened after it became known that in the United States, teenagers launched a challenge, the essence of which is to take high doses of an allergy drug called Benadryl to induce hallucinations. Boris Mendelevich, a member of the State Duma Committee on Health Protection, turned to the department with a request to remove this kind of content from the Russian Internet if possible.
Roskomnadzor responded to Mendelevich’s appeal, found 20 channels on TikTok, where videos of this content are posted. If the department finds more videos, it will block them too.
Not only Mendelevich and Roskomnadzor considered the content dangerous, but also Rosmolodezh. “Video recordings on the above links pose a threat to the life and health of minors,” the organization said in a letter, RIA Novosti reports.
Tiktokers named the challenge #Benadryl.As part of this competition, users drink large amounts of the allergy medicine Benadryl to induce hallucinations. Videos with the hashtag #Benadryl on TikTok gained about 5.5 million views at the end of July, and by the end of August the number of users interested in this topic had grown to six million.
“After taking Benadryl, I see people in my room”
This challenge really has negative consequences. At least three teenagers were sent to the hospital in May.Everyone went to Cook Children’s Medical Center. The doctors of the institution emphasized that Benadryl is a dangerous drug, an overdose of which is dangerous and can even lead to death. This is despite the fact that the drug is sold for some reason without a prescription.
“Excessive amounts of diphenhydramine (the active ingredient is Benadryl – ed.) Can cause heart palpitations and arrhythmias, as well as hallucinations and convulsions. In addition, overdose can cause urinary retention, so a urinary catheter may be required for treatment, ”said Nurse Amber Jevison.
Among the victims of “Benadryl” was 14-year-old blogger Rebecca. She took 14 tablets of the drug. The girl developed hallucinations, her speech became abrupt, and her pulse rose to 199 beats per minute (at a rate of 65 to 90).
Someone even thought of giving a drug to a dog. And this effect followed five minutes later.
Benadryl has a list of side effects due to a substance called diphenhydramine. In addition to a crazy increase in heart rate, the drug causes difficulty urinating, uncontrolled movement of the tongue, swelling of the face, lips, throat, shortness of breath, confusion, dizziness, drowsiness (due to the effect on the central nervous system), loss of coordination, dry mouth, indigestion, dry eyes, blurred vision, hangover.And this is only a part of those negative phenomena that may arise when taking Benadryl.
Allergic urticaria – (Clinic Di Center)
Urticaria – allergic skin reaction
Urticaria is a condition that causes bumpy, itchy, red blisters on the surface of the skin. This is usually due to an allergic reaction to food or drugs.
In the presence of an allergic reaction to any substance, the body begins to produce histamine and other substances that enter the bloodstream.This causes itching, tissue swelling, and other symptoms. Hives are a common reaction. People with other types of allergies, such as hay fever, may also develop hives.
When tissue edema and inflammatory streaks occur on the face, especially around the eyes and lips, it is called angioedema. Tissue swelling can also spread to the hands, feet, and throat.
Many substances can trigger the appearance of hives, for example:
Animal hair (especially cats)
Shellfish, fish, nuts, eggs, milk and other foods
Hives can also result from:
Excessive cold or sun exposure
Any medical condition, such as systemic lupus erythematosus, other autoimmune diseases, and leukemia
Infectious diseases such as mononucleosis
The appearance on the skin of edematous red or colorless streaks with clear edges.
The stripes can increase in size, spread to other parts of the body, merge with each other to form large areas of inflamed skin.
The streaks can also change shape, disappear or reappear within minutes or hours. When you press on the area of redness, it turns white, so you can tell that you have hives. This is called blanching.
A doctor can diagnose hives in you just by looking at your skin.
If you have allergies, the diagnosis becomes more obvious.
Sometimes skin biopsies or blood tests may be done to diagnose the presence of an allergic reaction and to identify the substance to which the allergy is developing.
Mild urticaria does not require treatment.She can walk on her own. To relieve itching and reduce swelling, follow these tips:
Do not take a hot bath or shower
Do not wear tight clothing, contact with which may irritate the skin
Your doctor may prescribe antihistamines such as diphenhydramine (Benadryl). Strictly follow your doctor’s instructions when taking these drugs.
For a severe allergic reaction, such as when swelling spreads to the throat, you may need an emergency injection of epinephrine (adrenaline) or steroids. Hives around the throat can block the airway and make breathing difficult.
Hives, as a rule, cause only discomfort, they are usually harmless and go away on their own.In most cases, it is not possible to accurately determine the cause of the development of urticaria.
Anaphylaxis (a life-threatening allergic reaction that makes breathing difficult)
Swelling in the larynx can lead to life-threatening blockage of the airways.
When to see a doctor
Call 103 for immediate medical attention if you have:
See your doctor if the hives are massive, uncomfortable, and persistent with home treatment.
Avoid contact with substances that provoke the development of an allergic reaction.
Avoid wearing tight clothing or taking a hot bath or shower immediately after having hives. This can provoke her reappearance.
This is a randomized, single-blind, placebo-controlled study to evaluate the efficacy of a subdissociative dose of ketamine versus standard therapy for the treatment of acute headache in patients admitted to the emergency department with headache as a primary subordinate.Standard care will include 25 mg of diphenhydramine (DIP) IV, 10 mg of metoclopramide (MET). Intravenous, +/- 15-30 mg ketorolac and +/- 10 mg dexamethasone (DEX) IV optional This study was approved by the Brook Army Medical Center (BAMC). Institutional Review Board and registration at clinictrials.gov is pending. A convenient sample of patients aged 18 to 65 years with the main complaint of headache. will be considered for admission. Potential subjects are those presenting SAMMC ED with a major headache complaint.Attempts to involve subjects in an earlier ED course (EDC). This will reduce the likelihood of interrupting the subject’s EDC. exclusion from the control group and lack of interest of subjects in the study. the nurse will inform the PI or AI of any patient presenting to the ED with a major complaint about Patients who meet the inclusion criteria, an information brochure will be provided. about research. If they wish to participate, the research team member will obtain written consent. Patient screening, enrollment, patient consent and data collection will be performed by the PI or AI.Each AI will complete training on research details, inclusion / exclusion. criteria, nebulization, intranasal delivery and pharmacokinetics of ketamine to be performed by the PI. Once the patient has received consent, the team member will receive the study package and the patient will receive a study identification number. the training package will contain the necessary forms, questionnaires, forms of Wand documentation. the research staff will then write on the patient a standard order sheet “SDDK Protocol, Patent # __, __kg” All women of childbearing age who have not had a hysterectomy or tubal ligation will have a pregnancy test, a standard test done in the emergency department and considered part of routine practice.A pregnancy test in women is a test that is required for all patients. passing this permit among other laboratories not applicable to this study. The baseline pain score will be determined using a visual analogue scale of 100 mm, described to the patient as “no pain” is 0 and “worst pain imaginable” is 100. is defined as eligible for enrollment if a baseline VAS score is obtained 50 or higher. The investigator then records the patient’s body weight and vital signs.Additional demographic data to be recorded will include age, gender, comorbidities, and Headache classification. Once a subject has been identified as meeting the inclusion / exclusion criteria and has agreed to participate in the study and have a signed consent form, the patient will be randomized via permutation block randomization to ketamine or standard care. Each subject will be assigned an intravenous catheter and an intravenous bag of 1000 ml saline will be started for each patient at the discretion of the physician62.the hand is received and is ready for administration, the IP or AI will fix the zero time. The standard treatment group will be 10 mg MET, 25 mg DIP and +/- 15-30 mg KET. and +/- 10 mg dexamethasone IV, 10 mg MET will be added to a 1000 ml normal saline bag and injected bolus until the 1000 ml saline bag is empty. the arm of standard care will inject the same volume of nebulized intranasal saline with a calculated dose of 0.75 mg / kg ketamine.The ketamine arm will be injected with the SDDK intranasally via a nebulizer based on previous research. in relation to intranasal administration of ketamine in ED at an initial dose of 0.75 mg / kg2. The Attending Nurse will prepare the SDDK using the weight-based dosing table found in each study. The Attending Nurse will give the AI / PI SDDK syringe for testing. and introduction. Each patient is also given 0.5 ml, 0.5-1 ml and 2.5 ml of normal saline boluses instead of DIP, +/- KET and +/- DEX for a maximum of three boluses.An additional 2 ml of saline bolus will be added to the 1000 ml saline bag instead of the MET and the 1000 ml saline bag will be bolted until the bag is empty. Approximately 30 minutes after the initial ketamine administration, subjects will be asked if they would like an additional dose of headache medication. to request additional medications, the patient may receive a single repeat dose of 0.25 mg / kg intranasal ketamine.This time was chosen empirically as a reasonable time for the clinic. overestimation of the analgesic effect. 60 minutes after taking all the drugs, the subject will participate in the study. will be completed and the planned emergency treatment will be resumed. At this time, each patient will be asked if they would like to receive additional headache medications. adjunctive medications, emergency analgesia may be prescribed at the discretion of the physician In addition, at any time, the treating physician considers that pain relief is inadequate, either by verbalizing the patient or in the judgment of the provider, rescue medications may be provided at the discretion of the treating physician.Researchers will record hand pain scores, vital signs, and side effects. after 10, 30, 60 and 90 minutes. The total treatment time will also be documented. Reported effects will be based on the side effect rating scale for dissociative anesthetics. (SERDA) and will include fatigue, dizziness, nausea, headache, feelings of unreality, changes in hearing, mood changes, general discomfort, and hallucinations. reported on a five-point scale, patients will be assessed for side effects with a “yes” or “no” answer.Side effects are considered serious if they are clinically apparent. symptoms that could not be eliminated by clinical intervention or tincture of time. At the time of discharge, the final pain score will be recorded using a 10-point numerical scale. rating score (NRS), where 0 means no pain and 10 means pain may increase. Patients will also be asked if they believe they have received investigational drug or routine care. the final ED satisfaction score will be recorded using a 10-point numerical rating.score (NRS): 0 means very dissatisfied and 1-0 means very satisfied. Follow-up will take place by phone using a phone call script (included in this package) at 48-72 hours after check-out. All subjects will be interviewed during script interviews. side effects when using SERDA elements and whether the patient continues to perceive the headache and the duration of the previous relief of the headache. Again, pain will be assessed using a 10-item NRS.Additional information will be collected during the subsequent communication. including but not limited to drug changes, new diagnoses, unscheduled visits or appointments. Subject will be prompted with contact information including telephone numbers and email addresses for Telephone contact will be the primary method of communication. If after two phone calls attempt, PI is unable to contact the patient, a script email will be sent asking the subject to contact protocol staff to complete the survey.unable to be contacted or lost for follow-up, additional contact numbers will be requested, if any. A system for working with veterans will be found if all other methods have been exhausted to no avail. the protocol team will attempt to contact the patient within 5 days of the date of discharge from the hospital. If the patient is not contacted, it is assumed that the time frame subjects are lost to follow-up. The primary outcome would be the change in pain level documented by the VAS from the study.start of discharge. Secondary outcomes will include treatment efficacy (time to pain relief), change in pain score from discharge to follow-up, and side effect profile using the SERDSA Questionnaire.