• Meclizine (Antivert)
• Dimenhydrinate (Dramamine)
• Diazepam (Valium)
• Lorazepam (Ativan)
• Metoclopramide (Reglan)
• Prochlorperazine (Compazine)
• Promethazine (Phenergan)

1. What Are the Most Common Causes of Vertigo?

Vertigo can be caused by acute unilateral vestibular lesions (Labyrinth or vestibular nerve) known as peripheral vertigo, or by lesions affecting the cerebellum or brainstem, known as central vertigo. The most common causes of vertigo are associated with the following disorders:

• Benign Paroxysmal Positional Vertigo
• Acute Vestibular Neuronitis
• Labyrinthitis
• Ménière’s Disease
• Migraine
• Anxiety disorders
• Vascular Ischemia or Stroke
• Acoustic Neuroma
• Cerebellar Degeneration
• Cerebellar Tumor
• Multiple Sclerosis
• Vestibular Ototoxicity
• Perilymphatic fistula

1.1. What Is Benign paroxysmal positional vertigo (BPPV)?

Benign paroxysmal positional vertigo (BPPV) is a disorder of the inner ear labyrinth that manifests with symptoms of episodic vertigo, loss of balance, dizziness, nausea, and vomiting.

It is caused by the displacement of calcium crystal structures within the inner ear saccule and utricle known as uroliths which help hair cells (stereocilia) in converting sound and head movement into neural signals.

The misplacement of these calcium crystal structures can be due to sudden head movement or head trauma [2].

1.2. What Is Labyrinthitis?

Labyrinthitis is the inflammation of the inner ear labyrinth causing symptoms such as vertigo, hearing loss, nausea, vomiting, and tinnitus [3].

Labyrinthitis is caused by viral and bacterial infection, and rarely by the formation of new bone in the inner ear labyrinth (Labyrinthitis Ossificans).

1.3. What Is Acute Vestibular Neuronitis?

Vestibular neuritis is the inflammation of the vestibulocochlear nerve which transmits to the brain, sound, and head movement neural signals that are received from hair cells.

Vestibular neuritis may be caused by infection with viruses such as herpes simplex virus (HSV-1), measles, mumps, or chickenpox [4].

1.4. What Is Ménière’s Disease?

Ménière’s disease is a disorder of the inner ear characterized by recurrent vertigo, tinnitus, and hearing loss. The causes of these diseases are unknown and may involve genetic and environmental factors [5].

1.5. What Is Vestibular Migraine?

Vestibular migraine is vertigo with migraine that does not necessarily manifest with headaches. The causes of vestibular migraine are unknown; however, genetic factors may be involved [6].

Vestibular migraine has been associated with Meniere’s disease and Benign paroxysmal positional vertigo (BPPV).

1.6. What Are Anxiety disorders?

Anxiety disorders are the most prevalent psychiatric disorders characterized by uncontrollable worries and fear associated with emotions, thoughts, ideas, and places.

Anxiety disorders can significantly affect the daily life of an individual and commonly manifest with symptoms, including irritability, focusing difficulties, chest pain, increased heart rate, and abdominal discomfort [7].

1.7. What Is Vascular Ischemia or Stroke?

Vascular ischemia or stroke are characterized by the reduction (ischemia) or absence (Stroke) of blood supply to the cerebellum or brainstem resulting in their damage and leading to acute vertigo.

1.8. What Is Acoustic Neuroma?

Acoustic neuroma or vestibular schwannoma is a tumor that develops from the Schwann cells on the vestibulocochlear nerve [8].

Schwann cells produce the Schwann myelin sheet that insulates nerves and helps with the transmission of nerve impulses.

The pressure from an acoustic neuroma on the vestibulocochlear nerve results in hearing loss, tinnitus, and unsteadiness.

Acoustic neuroma may be associated with neurofibromatosis type 2, a genetic disease characterized by tumors that grow along nerves.

1.9. What Is Cerebellar Degeneration?

Acquired cerebellum disorders are characterized by cerebellar degeneration associated with ischemic or hemorrhagic stroke, which limits blood flow or oxygen to the cerebellum.

These acquired disorders can also be associated with Multisystem atrophy, cerebellar cortical atrophy, and olivopontocerebellar degeneration.

Transmissible spongiform encephalopathies, such as Creutzfeldt-Jakob disease, can cause inflammation in the brain, including the cerebellum.

Damages to the neurons’ myelin sheath during diseases, such as multiple sclerosis can also affect nerve cells of the cerebellum.

Chronic alcohol abuse can lead to temporary or permanent cerebellar damage that can cause cerebellar degeneration.

Paraneoplastic disorders that are triggered by the body’s own immune system in response to cancers (e.g., lung, ovarian, lymphatic, or breast cancer) can result in the production of substances that cause immune system cells to attack neurons in the cerebellum leading to cerebellar degeneration.

1.10. What Is a Cerebellar Tumor?

Cerebellar tumors are lesions that mainly manifest with severe symptoms due to the compression of the cerebellum and adjacent brainstem or obstruction of cerebrospinal fluid (CSF) flow within the fourth ventricle [9].

The most common cerebellar are low-grade-gliomas which can cause symptoms such as gait ataxia and nystagmus

1.11. What Is Multiple Sclerosis?

The axons of neurons are covered by a sheath of a fatty acid (lipid), known as myelin, which insulates them and increases the rate of nerve impulses.

In multiple sclerosis (MS), the myelin sheath is damaged through a process called demyelination which disrupts the capacity of the affected neurons to conduct nerve impulses.

It is proposed that multiple sclerosis (MS) is due to a mix between genetics and infections; however, there is no evidence yet to support these hypotheses.

1.12. What Is Vestibular Ototoxicity?

Ototoxicity is the poisoning of the ear by chemicals or drugs that leads to damage to the inner ear causing balance and hearing difficulties.

1.13. What Is Perilymphatic fistula?

Perilymphatic Fistula is an abnormal opening between the inner ear and the surrounding structures due to congenital abnormalities or an injury (Head trauma, barotrauma) [10].

The symptoms of Perilymphatic Fistula include hearing loss, vertigo, tinnitus, dizziness, spatial disorientation, and nausea.

2. How Do I Know If I Have Vertigo or Dizziness?

Although dizziness and vertigo have been interchangeably used, dizziness is a perception associated with feeling light-headed and unsteady, while vertigo is the perception of being in movement or that your surrounding is in movement. 

3. How Is Vertigo Treated?

3.1. What Are Vestibular Rehabilitation Exercises?

Vestibular rehabilitation exercises are used in combination with antivertigo drugs and are aimed at training the brain to use different visual and proprioceptive signals to maintain gait and balance [11].

3.2. What Are Antivertigo Drugs?

Antivertigo drugs are used for the treatment of acute vertigo that lasts for hours to days.

3.2.1. What Is Meclizine?

Meclizine (Antivert, Bonine) is an antihistamine drug that blocks H1 receptors which prevents their activation by histamine.

Histamine is a well know actor in local immune responses, and is produced by mast cells and basophils; however, it is also an important neurotransmitter involved in itching following inflammation, and in the regulation of the sleep-wakefulness cycle [12].

Meclizine blockage of histamine binding to H1 receptors may reduce the function of the sensory vestibular organs and increase vestibulocochlear blood flow [13].

3.2.2. What Is Dimenhydrinate?

Dimenhydrinate (Dramamine, Draminate) is an antihistamine drug that blocks H1 receptors which prevents their activation by histamine. It has also an anticholinergic activity by inhibiting the activity of the neurotransmitter acetylcholine [14].

3.2.3. What Is Diazepam?

Diazepam (Valium) belongs to the class of drugs known as benzodiazepines which prevent the excitation of neurons by enhancing the effect of GABA on GABA_A receptors.

GABA (Gamma-Aminobutyric acid) is a chemical messenger and the major inhibitor of neurotransmission by reducing nerve impulses (action potential).

Therefore, it has an opposite action to that of glutamate and ensures balanced neurotransmission [15].

Benzodiazepines are used for the treatment of anxiety, panic disorder, sleep disorders (e.g., insomnia), epileptic seizures, as a muscle relaxant, and for the treatment of alcohol withdrawal.

3.2.4. What is Lorazepam?

Lorazepam (Ativan) also belongs to the benzodiazepines family of drugs which act by preventing the excitation of neurons through enhancing the effect of GABA on GABA_A receptors.

3.2.5. What Is Metoclopramide?

Metoclopramide (Reglan) is an antiemetic (prevent nausea and vomiting) drug that is mainly used for post-chemotherapy nausea and vomiting.

Metoclopramide is a blocker of serotonin receptors known as 5-HT3 receptors. Serotonin is a chemical messenger involved in the neurotransmission of information related to mood, reward, learning, memory, and cognition. 

3.2.6. What Is Prochlorperazine?

Prochlorperazine (Compazine) is an antiemetic, antipsychotic, and anxiolytic drug that inhibits the dopamine receptors known as dopaminergic D₂ receptors in the central nervous system.

Dopamine is an organic chemical involved in the transmission of instructions between neurons to control movement and reward-motivated behavior, such as pleasure, craving, decision making based on rewards, associative learning (learning new things), and short-term memory [16].

3.2.7. What Is Promethazine?

Promethazine (Phenergan) is an antihistaminic, antiemetic, and antipsychotic drug that mainly blocks H1 receptors, and therefore, prevents their activation by histamine. It has also a moderate anticholinergic activity.

Conclusion

Vertigo can be physiologic such as motion sickness; however, it can also be caused by disorders that require antivertigo drugs.

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1. What Is Excitability and Irritability?

Excitation is a physiologic transition from a state of rest to a state of brain activity caused by stimuli, while irritability is the ability to respond to stimuli with an excessive sensitivity after excitability.

Irritability is also one of the symptoms of anxiety but also a symptom associated with several psychological and neurological disorders.

2. What Are Anxiety Disorders?

Anxiety disorders are the most prevalent psychiatric disorders characterized by uncontrollable worries and fear associated with emotions, thoughts, ideas, and places.

Anxiety disorders can significantly affect the daily life of an individual and commonly manifest with symptoms, including irritability, focusing difficulties, chest pain, increased heart rate, and abdominal discomfort [1].

2.1. What Are the Types of Anxiety Disorders?

There are several types of anxiety disorders, including:

• Panic Disorder
• Agoraphobia
• Generalized Anxiety Disorder
• Social Anxiety Disorder (Social Phobia)
• Specific Phobia
• Separation Anxiety Disorder
• Selective Mutism
• Mixed Anxiety and Depressive Disorder

2.1.1. Panic Disorder

A panic disorder is characterized by sudden and repeated episodes of intense fear attacks that physically manifest with the following symptoms:

Palpitations

• Tremor
• Chest pain
• Sweating
• Palpitations
• Feeling of choking
• Abdominal discomfort
• Paraesthesia (Abnormal sensations of the skin)
• Feeling of unreality

2.1.2. What Is Agoraphobia?

Agoraphobia is the fear of being unsafe in places such as closed spaces, public transports, crowds, elevators, or being outside of the home, and which results in panic attacks.

2.1.3. What Is Generalized Anxiety Disorder?

Generalized anxiety disorder is characterized by excessive and unrealistic worries about events and activities. It manifests with the following symptoms:

• Palpitations
• Tremors
• Nausea
• Dizziness
• Muscle tension
• Insomnia
• Nervousness
• Constant worries

2.1.4. What Is Social Anxiety Disorder?

Social anxiety disorder or social phobia is characterized by a fear of being the center of attention in situations where we might be negatively evaluated, such as public speaking, job evaluation by line managers, or discussion with persons from the opposite sex.

2.1.5. What Is Specific Phobia?

Specific phobia is characterized by an overwhelming fear of a specific situation (e.g., Airplanes), animal (e.g., Spider), or natural phenomena (e.g., Heights).

2.1.6. What is Separation Anxiety Disorder?

Separation anxiety disorder is an overwhelming fear of being separated from places or individuals to whom we are attached. This anxiety disorder is only diagnosed in children.

2.1.7. What Is Selective Mutism?

Selective mutism is characterized by the fear to speak in situations in which the individual is expected to speak while being able to speak in other situations.

2.1.8. What Is Mixed Anxiety and Depressive Disorder?

Mixed anxiety and depressive disorder is characterized by the presence of a balanced mix of anxiety and depression symptoms which makes a diagnosis of either anxiety disorder or depression difficult.

2.2. How Are Anxiety Disorders Treated?

Treatment of anxiety disorders involves lifestyle changes, psychotherapy, and pharmacotherapy (medications).

Lifestyle changes involve:

• Tacking a time out to clear your head
• Limiting alcohol and caffeine consumption
• Getting enough sleep
• Consumption of well-balanced meals
• Exercising to maintain health and reduce stress
• Maintaining a positive attitude
• Learn about your anxiety disorder and what triggers it.

Psychotherapy involves cognitive behavioral therapy which involves changing and challenging distorted behaviors, thoughts, beliefs, and attitudes, to reduce the symptoms of anxiety disorders.

However, if the symptoms of the anxiety disorder are severe such as suicidal thoughts, alcohol abuse, or secondary depression, anxiolytics are used to alleviate the symptoms.

3. What Are Sedatives and Anxiolytics?

Sedatives and anxiolytics are used to alleviate symptoms of anxiety, treat insomnia, and reduce excitation and irritability to restore calmness.

They grouped into the following categories:

• Barbiturates
• Benzodiazepines
• Selective Serotonin Reuptake Inhibitors
• Miscellaneous Sedatives and anxiolytics

3.1. What Are Barbiturates?

Barbiturates are used for the treatment of anxiety, insomnia, and epileptic seizures. They exert their effects by enhancing the activity of GABA.

GABA (Gamma-Aminobutyric acid) is a chemical messenger and the major inhibitor of neurotransmission by reducing nerve impulses (action potential).

They also bind to AMPA receptors which prevent the binding of glutamate and block the excitation of neurons.

Barbiturates include drugs such as primidone (Mysoline), phenobarbital (Luminal, Mebaral), butabarbital (Butisol), and pentobarbital (Nembutal).

3.2. What Are Benzodiazepines?

Benzodiazepines prevent the excitation of neurons by enhancing the effect of GABA on GABA_A receptors.

GABA (Gamma-Aminobutyric acid) is a chemical messenger and the major inhibitor of neurotransmission by reducing nerve impulses (action potential).

Therefore, it has an opposite action to that of glutamate and ensures balanced neurotransmission [2].

Benzodiazepines are used for the treatment of anxiety, panic disorder, sleep disorders (e.g., insomnia), epileptic seizures, as a muscle relaxant, and for the treatment of alcohol withdrawal.

Benzodiazepines include drugs such as diazepam (Valium), midazolam (Versed), clonazepam (Klonopin), clobazam (Onfi), lorazepam (Ativan), temazepam (Restoril), flurazepam (Dalmane), oxazepam (Serax), and clorazepate (Tranxene T-Tab).

3.3. What Are Selective Serotonin Reuptake Inhibitors (SSRIs)?

Selective serotonin reuptake inhibitors (SSRIs) increase extracellular neuronal concentrations of serotonin by inhibiting its reuptake by monoamine transporters; however, this high concentration results later in the downregulation of serotonin receptors, and therefore, serotonin activity.

Serotonin is a chemical messenger involved in the neurotransmission of information related to mood, reward, learning, memory, and cognition.

Selective serotonin reuptake inhibitors (SSRIs) are primarily used as antidepressants for the treatment of major depression but also for anxiety disorders.

SSRIs include drugs such as citalopram (Celexa), fluoxetine (Prozac), paroxetine (Paxil), escitalopram (Lexapro), and sertraline (Zoloft).

3.3. What Are Miscellaneous Sedatives and Anxiolytics?

Miscellaneous sedatives and anxiolytics are drugs that cannot be classified into the above categories due to their different mechanisms of action.

They are used in the treatment of anxiety, insomnia, alcohol withdrawal, opiates, or barbiturates withdrawal, and for post-operative pain.

Miscellaneous sedatives and anxiolytics include drugs such as buspirone (Buspar), diphenhydramine (Tranquil), doxylamine (Unisom), sodium oxybate (Xyrem), zolpidem (Ambien), melatonin, and ramelteon (Rozerem).

Conclusion

Excitation and irritability are symptoms of anxiety disorders and medications that treat them are also used for the treatment of anxiety disorders.

However, sedatives and anxiolytics are mainly used for severe anxiety disorders, while mild and moderate symptoms are treated through lifestyle changes and cognitive behavioral therapy.

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