A 52-year-old woman presents with recurrent episodes of severe vertigo lasting 20 minutes to 2 hours, accompanied by unilateral tinnitus, hearing loss, and a sensation of fullness in the left ear. Audiometry confirms low-frequency sensorineural hearing loss. MRI rules out retrocochlear pathology. She has failed conservative management with salt restriction and diuretics. What is the drug of choice for acute vertigo attacks in Meniere disease?

## Acute Vertigo Management in Meniere Disease ### Classification of Meniere Disease Medications Meniere disease treatment is stratified by attack phase and severity: | Phase | Goal | Drug Class | Examples | |-------|------|-----------|----------| | **Acute attack** | Symptom relief | Antiemetics, vestibular suppressants | Prochlorperazine, meclizine | | **Prophylaxis** | Reduce frequency | Diuretics, histamine analogues | Thiazides, betahistine | | **Refractory** | Long-term control | Intratympanic corticosteroids, gentamicin | Dexamethasone, gentamicin | ### Why Prochlorperazine Is Correct **Key Point:** Prochlorperazine is the first-line drug for acute vertigo attacks in Meniere disease because it combines antiemetic and vestibular suppressant properties. **Mechanism:** 1. Dopamine antagonist → antiemetic effect via chemoreceptor trigger zone 2. Central vestibular suppression → rapid symptom relief 3. Rapid onset (15–30 minutes IM/IV) suitable for acute crisis **High-Yield:** In acute Meniere attack, the priority is **immediate symptom relief** during the attack phase, not long-term prophylaxis. Prochlorperazine achieves this fastest. **Clinical Pearl:** Prochlorperazine can be given IM or IV during severe attacks when oral intake is compromised by nausea/vomiting, making it superior to oral alternatives. ### Role of Other Agents - **Betahistine:** Histamine H₁/H₃ receptor agonist; used for **prophylaxis** (reduces attack frequency), not acute management. Takes days to weeks to be effective. - **Meclizine:** Anticholinergic vestibular suppressant; slower onset than prochlorperazine; primarily for motion sickness, not acute vertigo crisis. - **Cinnarizine:** Calcium channel blocker with vestibular effects; used in some countries for prophylaxis, not first-line for acute attacks in India/NEET PG curriculum. **Mnemonic:** **PAVE** for acute Meniere vertigo management: - **P**rochlorperazine (first-line acute) - **A**ntiemetic effect - **V**estibular suppression - **E**ffective IM/IV route ### Treatment Algorithm ```mermaid flowchart TD A[Meniere Disease Attack]:::outcome --> B{Severity?}:::decision B -->|Acute severe| C[Prochlorperazine IM/IV]:::action B -->|Mild-moderate| D[Meclizine or prochlorperazine oral]:::action C --> E[Symptom relief in 15-30 min]:::outcome D --> F[Symptom relief in 30-60 min]:::outcome A --> G{Prophylaxis needed?}:::decision G -->|Yes| H[Betahistine or thiazide diuretic]:::action G -->|No| I[Conservative: salt restriction, fluid balance]:::action ``` **Key Point:** Do not confuse acute attack management with prophylaxis. Prochlorperazine is for **acute**, betahistine is for **prevention**.