Intravenous Sodium Bicarbonate for the Treatment of Vertigo

Vertigo is characterized by a false sensation of movement typically described as spinning distinct from the lightheadedness associated with presyncope. Patients often report the perception that either they or their surroundings are in motion. Associated symptoms may include hearing loss, imbalance, tinnitus, and nausea or vomiting. Vertigo accounts for approximately 3 million emergency department visits annually in the United States, with an estimated lifetime prevalence of 2.4%. Each episode costs roughly $2,000 in diagnostic and treatment expenditures, contributing to nearly $2 billion in healthcare costs per year. Although symptoms may last only seconds to minutes, in some patients vertigo can persist for days and significantly impair quality of life. Standard treatment strategies focus on repositioning maneuvers to relocate dislodged otoliths within the vestibular system. Pharmacologic options commonly used in the emergency setting include antihistamines and benzodiazepines. Antihistamines such as meclizine and diphenhydramine have demonstrated benefit since the 1940s through H1 receptor blockade, thereby reducing histaminergic input and attenuating vertigo symptoms. Benzodiazepines, via potentiation of gamma‑aminobutyric acid (GABA) activity, provide symptomatic relief by suppressing vestibular pathway excitability and reducing the anxiety that often accompanies acute episodes. While both drug classes remain frequently cited, emerging evidence suggests antihistamines may offer superior efficacy for acute symptom control. Despite this, the Otolaryngology–Head and Neck Surgery guidelines for Benign Paroxysmal Positional Vertigo recommend against the use of benzodiazepines or antihistamines due to concerns regarding sedation, medication interactions, potential harm, and reduced diagnostic accuracy during positional testing such as the Dix–Hallpike maneuver. More recently, sodium bicarbonate has emerged as a potential therapeutic option. Animal studies indicate that sodium bicarbonate may decrease firing of medial vestibular nucleus neurons, processes involved in balance pathways, thereby reducing vertigo-related signaling. Additional animal models suggest that sodium bicarbonate may lower cochlear blood flow, alleviating symptoms associated with localized edema or fluid accumulation that exacerbate vertigo. Recent human studies have shown comparable efficacy to diphenhydramine with significantly less sedation. Furthermore, combination therapy with sodium bicarbonate and antihistamines may produce synergistic effects, enhancing overall symptom relief. However, data remains limited, and randomized controlled trials are sparse. Current guidelines discourage routine pharmacologic treatment of vertigo due to concerns about adverse effects and diagnostic interference. Nonetheless, emerging studies evaluating non-sedating alternatives such as sodium bicarbonate demonstrate promising efficacy with minimal side effects. Further research is needed to define the optimal patient population, dosing strategies, and combination regimens for managing vertigo in the emergency department.