Simpler Drug Regimens May Shorten Emergency Department Stays for Vertigo Patients

For patients who arrive at an emergency department with the room spinning around them, the difference between going home in eight hours or staying nearly eleven can hinge on something surprisingly mundane: how many medications they are given. A new observational study from Tehran suggests that the complexity of the pharmacological cocktail handed to people with peripheral vertigo is one of the strongest treatment-related predictors of how long they remain in the department, a finding with immediate implications for one of the most common and resource-hungry complaints in emergency medicine.

The research, published in the Journal of Emergency and Disaster Medicine, examined 96 adult encounters for acute peripheral vertigo at Rasool-e-Akram Hospital in Tehran between January and June 2024. Peripheral vertigo, in which the sensation of spinning originates in the inner ear rather than the brain, is most often caused by benign paroxysmal positional vertigo, vestibular neuritis, or Ménière’s disease. Yet because these same symptoms can occasionally signal a stroke, emergency clinicians face a diagnostic tightrope: they must rule out dangerous central causes while relieving distressing symptoms and keeping patients moving through a crowded department.

The research team, led by emergency medicine physicians and researchers affiliated with Iran University of Medical Sciences, conducted a cross-sectional review of patient charts, excluding anyone with a documented central cause of vertigo, incomplete management records, or a history of chronic vertigo. The cohort, with a mean age of 60.3 years and a striking 68.8 percent female majority, was analyzed for five vertigo-specific drugs commonly used in emergency settings: ondansetron, betahistine, promethazine, metoclopramide, and benzodiazepines such as diazepam. The primary outcome was length of stay, measured in minutes from documented arrival to physical departure from the department.

The headline result was stark. Patients who received three or more distinct vertigo medications stayed a median of 652 minutes, compared with 467.5 minutes for those given two or fewer drugs, a difference that held up under non-parametric statistical testing. In a multivariable linear regression adjusted for age, sex, consultation patterns, and self-discharge status, complex regimens were independently associated with an additional 180.9 minutes of department time, with a 95 percent confidence interval of 76.0 to 285.7 minutes and a p-value of 0.0009. The mean stay in the simple-regimen group was 528 minutes, while the complex-regimen group averaged 752.3 minutes, a gap of nearly four hours.

Drug-specific analyses sharpened the picture further. Benzodiazepines, the sedating class often deployed to dampen the anxiety and vestibular storm of acute vertigo, were strongly linked to longer stays, adding an estimated 356.2 minutes even after adjustment for regimen complexity and consultations. The authors suggest this may reflect the sedation burden such drugs impose, which typically mandates prolonged observation before patients can be safely discharged. Promethazine, by contrast, was independently associated with a shorter stay, reducing department time by an estimated 161.3 minutes, possibly because it achieves faster symptom control or because clinicians reserve it for more straightforward presentations. Ondansetron, betahistine, and metoclopramide showed no clear independent association, though the authors caution that small exposed groups and confounding by indication, in which sicker patients receive certain drugs, make these estimates imprecise.

Consultations emerged as the other major lever on throughput. Neurology was the most frequently requested specialty, consulted in 28.1 percent of encounters, followed by cardiology at 15.6 percent. More than half of visits required no consultation at all, but 40.6 percent involved one and 7.3 percent involved two. In the adjusted model, neurology consultation added an estimated 163.9 minutes, while internal medicine and ear, nose, and throat consultations were associated with even larger increases of 501.3 and 476.0 minutes respectively, all statistically significant. The authors interpret these large effects not as evidence that the consultations themselves are wasteful, but as a signal that their involvement flags clinically challenging presentations, such as cardiovascular comorbidity or overlapping otologic disease, that demand additional diagnostic workup.

The prescribing patterns documented in the study reveal a clear hierarchy of practice. Ondansetron, a serotonin-receptor antagonist used to control vertigo-related nausea, was the first drug ordered for nearly half the cohort and was administered at some point to more than 70 percent of patients, consistent with international guideline support for this class. When a second-line agent was needed, betahistine topped the list, reflecting its long-standing track record in peripheral vestibular disease. Diazepam appeared in a smaller number of regimens, hinting at clinicians’ awareness of the anxiety that frequently accompanies acute vertigo, a dimension emphasized in the psychosocial literature on vestibular disorders.

The authors are careful to frame their findings as hypothesis-generating rather than prescriptive. Because the study lacked standardized measures of vertigo severity or clinical acuity at arrival, it is entirely possible that patients who appeared more unwell both received more medications and required longer observation, meaning residual confounding by illness severity may partly explain the association between regimen complexity and longer stays. The single-center design, the absence of data on time to symptom relief, functional outcomes such as safe ambulation at discharge, and unplanned return visits, and the inability to analyze non-pharmacologic interventions like canalith repositioning maneuvers all constrain the conclusions. Rare consultation types produced wide confidence intervals that larger samples would need to tighten.

Even so, the operational message resonates with a broader body of evidence linking polypharmacy and regimen complexity to slower hospital throughput in other acute conditions, from bronchiectasis to sedation-heavy critical care. The findings align with expert recommendations favoring stepwise pharmacotherapy, in which drugs are added sequentially as needed, rather than simultaneous multi-drug administration from the outset. They also echo prior reports that specialty input, while essential when central causes are suspected, can inadvertently lengthen emergency department stays when requested routinely rather than selectively for peripheral vertigo.

The study’s authors propose that emphasizing focused bedside assessment, tools such as the head-impulse, nystagmus, test-of-skew examination, stepwise rather than simultaneous drug therapy, and judicious specialty consultation could improve both the quality and the pace of vertigo care. Prospective, multi-center interventional studies will be needed to determine whether pathways built on these principles can safely shorten emergency department stays without compromising diagnostic safety, particularly given the stakes of missing a stroke masquerading as benign dizziness. For now, the study offers emergency departments a concrete, testable target: fewer drugs, chosen deliberately, may be the fastest route to getting dizzy patients back on their feet and out the door.

Subject of Research: The association between pharmacological treatment complexity, specialty consultations, and emergency department length of stay in adults with acute peripheral vertigo.

Article Title: Therapeutic approaches and their association with hospitalization duration in patients with peripheral vertigo presenting to the emergency department

Article References: Therapeutic approaches and their association with hospitalization duration in patients with peripheral vertigo presenting to the emergency department. (n.d.). https://doi.org/10.1007/s44467-025-00007-4

Image Credits: AI Generated

DOI: 10.1007/s44467-025-00007-4

Keywords: peripheral vertigo, emergency department, length of stay, polypharmacy, benzodiazepines, promethazine, betahistine, ondansetron, neurology consultation, vestibular disorders, regimen complexity, emergency medicine