Otolaryngology

Comparison of efficacy dimenhydrinate and metoclopramide in the treatment of nausea due to vertigo; a randomized study

a b s t r a c t

Background: This study aimed to compare the therapeutic efficacy of dimenhydrinate and metoclopramide in pa- tients with nausea and vertigo.

Methods: A prospective, double-blind, randomized clinical trial was performed on patients who presented to the emergency department (ED) with nausea and vertigo in the six month period between Nov 1st 2012 and May 1st 2013. Adult patients who were 18 to 65 years old presenting to the ED with nausea and vertigo or motion sick- ness were included in the study. A total of 200 patients were divided into 2 groups who were admitted to ED with complaints of vertigo accompanied by nausea. In the first group, 50 mg dimenhydrinate and 10 mg metoclopramide infusions were given intravenously for 15 min. The efficacy of treatment was measured by using a 10 mm Visual analog scale performed at 0, 15 and the 30th minute. The primary outcome variable was a reduction in vertigo intensity documented on the VAS at the 30th minute after medication administration. Results: A total of 200 patients were included in the randomization (n=100 in both groups). The baseline vertigo VAS scores were 7.57+-1.42 in the dimenhydrinate (DMT) group and 7.27+-1.40 in the metoclopramide (MTP) group (p=0.09). In the 30th minute of treatment, the average vertigo VAS score was 2.46 +- 2.39 in the DMT group and 2.31+-1.96 in the MTP group; no significant differences were detected between groups. The baseline nausea VAS scores were 7.62+-1.48 in the DMT group and 7.45+-1.27 in the MTP group (p=0.36). In the 30th minute of treatment the average vertigo VAS score decreased to 2.27+-2.24 in the DMT group and 2.70+-2.48 in the MTP group, no significant differences were detected between groups. No significant differences were de- tected between nausea VAS changes and vertigo VAS changes at 30th minutes of the treatment (p=0.06, p=0.85 respectively). Rescue medication need was similar in both treatment groups (p=0.94). No significant differences were detected about the side effects which are sedation (p=0.56) and hypotension (p=0.57).

Conclusions: In conclusion, this prospective, double-blind, randomized study showed that both DMT and MTP have similar efficacy in reducing nausea and vertigo symptoms in the ED.

(C) 2020

  1. Introduction

Vertigo is a symptom defined as a type of dizziness or hallucination of movement of oneself or surroundings [1,2]. It describes the illusion of being exposed to an automatic movement [3]. In a study conducted in 2013, the lifetime prevalence of vertigo calculated for 7.8% of the

Abbreviations: ED, Emergency Department; VAS, Visual Analog Scale; DMT, Dimenhydrinate; MTP, Metoclopramide; PONV, Postoperative Nausea and Vomiting; NRS, Numeric rating scale.

* Corresponding author at: Kafkas University Faculty of Medicine, Department of Emergency Medicine, 36100, Kars, Turkey.

E-mail address: [email protected] (D. Ercin).

general adult population, with a remarkable female dominancy and an increased prevalence in the elderly population [4]. At least 3.3% of all annual emergency department (ED) visits are associated with dizzi- ness or vertigo as a presenting symptom according to a surveyance study in 2013 [5]. Rapid diagnosis and appropriate treatment should be performed in the ED because it harms personal daily activity and the healthcare system [6]. Commonly vertigo associated symptoms are nausea, emesis, and sweating [7]. Nausea is entirely subjective and commonly described as the sensation that immediately precedes vomiting [8].

Antihistamines are considered as vestibular suppressants [9]. Di- menhydrinate (DMT) consists of equimolar proportions of diphenhy- dramine and 8-chlorotheophylline verified beneficial for vertigo and

https://doi.org/10.1016/j.ajem.2020.12.010

0735-6757/(C) 2020

available for parenteral administration [2,10]. It acts as a depressant role in hyperstimulated labyrinthine function and antiemetic effects were believed to be antihistamine [3].

Metoclopramide (MTP) which is used extensively in the ED practice for the treatment of vomiting, vascular-type headache and nausea, acts mainly by blocking especially D2 subtype of dopaminergic receptors in the brain, also it is a 5-hydroxytryptamine 3 receptor antagonist at high concentrations [8,11-14].

Thus, effective antivertigo treatment in the ED is important in the early control of the vertigo-related symptoms eg. nausea. DMT is fre- quently used as a monotherapy or combined therapy in the treatment of vertigo [3,6,15-17]. MTP alone or as a combined therapy in the treat- ment of postoperative nausea and vomiting, dyspepsia [18-20].

In particular, there is a paucity of data comparing the efficacy of metoclopramide versus dimenhydrinate in patients who have had nau- sea and vertigo. We aimed to determine the effectiveness of whether metoclopramide or dimenhydrinate in relieving the symptom of nausea associated vertigo in the ED.

  1. Metods
    1. Study design

We performed prospective, randomized, single-center, double-blind study with patients who admitted to the ED with nausea associated with vertigo.

The efficacy of intravenous dimenhydrinate and intravenous metoclopramide in nausea associated with vertigo was compared in two parallel and randomized treatment groups. The research was per- formed in accordance with the tenets of the Declaration of Helsinki. Eth- ical approval (No: 2010:10-09/08/2012) was provided from Institutional review board of Pamukkale University Medical Faculty and T.C. Ministry of Health, General Directorate of Pharmaceuticals and Pharmacy, Clinical Researches Department (No: 90837:31/08/ 2012).

Before enrollment in the study we gave all patients oral and written information about the study and written consents of all patients were obtained. The study was performed between November 1st 2012 and May 1st 2013 at the ED of a tertiary Hospital. The University hospital is an 810-bed university hospital with 128,000 ED visits per year.

    1. Selection of participants

We included patients who were 18 to 65 years and had nausea asso- ciated with vertigo or motion sickness. Vertigo was defined as the illu- sory sense of movement or orientation. Motion sickness was also defined as nausea, vomiting, pallor, cold and sweating associated with sea and road traveling [21]. Baseline nausea measured at least 5 cm or more on a 10 cm visual analog scale [22].

Exclusion criteria were patients who refused to give consent, had hy- persensitivity or contraindication to dimenhydrinate and metoclopramide, were pregnant or breast-feeding, suspected/proven gastrointestinal hemorrhage, suspected/sustained mechanical Bowel obstruction and perforation, had a positive history of psychiatric or neurologic disorder (e.g., organic brain disease, migraine, epilepsy, Parkinson’s disease, cere- brovascular or Cardiac conditions, transient ischemic attack), known renal failure, nausea associated with vertigo rated <4 cm on a VAS. A previously specified physician who was not involved in the work shift; treated patients who refused to participate in study enrollment. In ad- dition to DMT or MTP treatment, patients were treated with Eppley maneuver, betahistine tablets, piracetam tablets.

    1. Protocol and measurements

Randomization was performed using computer software (http:// www.randomization.com, accessed 25 May 2013) to generate random

numbers. The randomization scheme was delivered to the study nurse who was responsible for preparing the treatments before the study was started. The drugs were prepared and labeled previously with the study number in 5 cc syringes by the same nurse who had information about the study drug only. Administration of the drug was performed in each approach by an implementing nurse, who was blinded to the study. The study nurse had no direct communication with the implementing nurse. The patients, physician and statistician were blinded to study protocol. The patients who were appropriate for the study were allocated to two groups in a 1:1 ratio, to receive a single dose of an intravenous dose of dimenhydrinate (Dramamine; Ali Raif Ilac San., Istanbul, Turkey) (1 cc,50 mg in 150 mL normal saline solu- tion) or metoclopramide (Primperan, Biofarma, Istanbul, Turkiye) (2 cc,10 mg in 150 mL normal saline solution). The duration of the infu- sions was determined as 15 min for both study groups. While measur- ing the degree of nausea and vertigo, a scoring of VAS scale (0 = no vertigo, 10 = worst possible vertigo) was used, which was 1-10 cm.

Patients nausea and vertigo VAS scores were measured at 0, 5, 15 and 30th min and systolic and diastolic blood pressure also were re- corded at the 0, 15 and 30th min from the beginning of intravenous ad- ministration. Patients were told to mark a point on the scale in accordance with the severity of the symptom. The location of the sign allows measuring the severity of the symptom. During the procedure, the patients were asked to put other marks without showing the previous mark.

Demographic data, address, phone numbers, medical history, dura- tion of vertigo, prior medical treatment, concomitant diseases, medica- tions were registered on the administration of ED by the physician. Detailed physical and Neurological examinations of all patients were evaluated by the same physician. During the procedure, participants were monitored using a Spacelabs (SpO2, oxygen saturation), automatic sphygmomanometer (blood pressure). Heart rate, systolic blood pres- sure, diastolic blood pressure were recorded at baseline (0) and at 15 and 30 min. Blood pressure was measured with Nihon Kohden(R) BSM- 2301 K brand device. During the study, Adverse drug reactions like seda- tion and hypotension and also all medications were recorded. Sedation was described as: patient drowsiness or eyes shut but could be stimu- lated using only a verbal command [23]. Mean systolic blood pressure below 90 mmHg and arterial pressure below 60-65 mmHg is defined as hypotension [24]. Patients who had insufficient relief (VAS < 5 mm) for vertigo and associated nausea sensation at the 30th minute received a drug for rescue medication.

rescue treatment was determined as a single dose of 5 mg diazepam in 100 mL normal saline solution for patients who had insufficient relief of vertigo and as a single dose of 5 mg granisetron in 100 mL normal sa- line solution for patients who had insufficient relief of nausea [25].

    1. Outcome measures

The primary outcome variable was a reduction in vertigo intensity documented on the VAS at the 30th minute after medication adminis- tration. The secondary outcome measures were reduction in nausea in- tensity documented on the VAS scale and the change in VAS scores for vertigo and nausea at the 30th minute after medication administration.

    1. Statistical analysis

Estimation of the sample size was determined using GPower 3.1 (Franz Faul Universitat Kiel, Germany,1992-2019). In order to detect a minimal difference of 1.5 points in the mean changes of VAS vertigo scores between two groups with a power of 95% where p = 0.05 was considered significant, a critical sample size was estimated to be 88 pa- tients/group. Assuming a 20% dropout rate, the final sample size was es- timated to be 100 patients/group. A sample size capable of detecting a change of a minimum clinically important difference between groups

of 1.5 points was estimated using the expected standard deviation for change in VAS vertigo obtained from a previous study [26].

Statistical analyses were conducted using SPSS software version 17.0 for Windows (SPPS Inc., Chicago, Ill). Descriptive analyses were pre-

Table 1

Baseline characteristics of the study population.

Dimenhydrinate (n = 100)

Metoclopramide (n = 100)

sented as mean +- SD for continuous variables and as frequency and per- centage for categorical variables. The Kolmogorov-Smirnov test was performed to examine the normality of the data. An independent sam- ples t-test was applied to examine the mean difference between the two independent groups for normally distributed variables. Mann-Whitney U test was applied to examine the median difference between the two independent groups for non-normally distributed variables. If appropri- ate; Chi-square test was applied to examine proportions or prevalence between the groups. Friedman test was used to compare for repeated measures like VAS nausea, vertigo, heart rate, blood pressure and p < 0.05 was considered statistically significant.

  1. Results

During the study period (01.11.2012-01.05.2013), A tertiary Univer- sity Adult Emergency Department admitted a total of 32,044 patients, 842 of whom admitted with vertigo. In 253 (0.8%) of these patients, nausea and vertigo. Afterward, excluding 53 of the patients 200 patients were involved in the study. All randomized patients completed the study (Fig. 1).

200 Of the cases; 144 (72%) of the patients were female, 56 (28%) were male, and the mean age was 31.15 +- 12.42 (mean +- SD), and the median body weight was 67.72 +- 13.26 (mean +- SD). No statisti- cally significant differences were detected between the groups in terms of patients’ sociodemographic and baseline characteristics (p > 0.05, all) (Table 1).

Additionally, DMT and MTP treatment decrease vertigo VAS scores over time. The initial vertigo VAS score of the DMT group was 7.57 +-

Age(mean +- SD) 32.95 +- 13.95 29.35 +- 10.43

Gender n (%)

Male

27(27)

29(29)

Female

73 (73)

71(71)

Body weight (mean +- SD) 67.18 +- 14.16 68.27 +- 12.35

Allergy n, (%)

14 (14)

7(7)

Disease n, (%)

34 (34)

21 (21)

Smoking n, (%)

33 (33)

33(33)

Medication n, (%)

36 (36)

25(25)

Systolic blood pressure (mean +- SD)

114.87 +- 20.70

113.34 +- 15.98

Diastolic blood pressure (mean

68.86 +- 11.65

69.68 +- 11.29

+- SD)

VAS vertigo 0TH min (mean +- SD)

7.57 +- 1.42

7.27 +- 1.40

VAS nausea 0TH min (mean +- SD) 7.62 +- 1.48 7.45 +- 1.27

1.42; it dropped to 2.46 +- 2.39 at the 30th minute (p < 0.001). The ini- tial vertigo VAS score of the MTP group was 7.27 +- 1.40; it dropped to

2.31 +- 1.96 at the 30th minute (p < 0.001) (Table 2). There was no sta- tistically significant difference between the two groups concerning ver- tigo VAS scores at the 30th minute (p = 0.77) (Table 2).

DMT and MTP intervention decreases nausea VAS scores over time. The initial nausea VAS score of the DMT group was 7.62 +- 1.48; it fell to 2.27 +- 2.24 at the 30th minute (p < 0.001). The initial nausea VAS score of the MTP group was 7.45 +- 1.27; it fell to 2.70 +- 2.48 at the 30th minute (p < 0.001) (Table 2). There was no statistically significant difference between the two groups concerning nausea VAS scores at the 30th minute (p=0.25) (Table 3).

Moreover, vertigo VAS changes at the 30th minute were calculated as 5.14 +- 2.25 in the DMT group and 4.99 +- 2.20 in the MTP group

Image of Fig. 1

Fig. 1. Patient flow chart.

Table 2

Time-linked change in vertigo VAS scores in groups.

Table 5

Time-linked change in Systolic blood pressure scores in groups.

VAS nausea scores (mean +- SD)

Dimenhyrinate (n = 100)

Metoclopramide (n = 100)

p?

Systolic blood pressure

Dimenhydrinate (n = 100)

Metoclopramide (n = 100)

p?

VAS 0TH MIN

7.57 +- 1.42

7.27 +- 1.40

mean +- SD

min.

mean +- SD

min.

p?? <0.001 <0.001

VAS 5TH MIN

5.78 +- 1.88

5.48 +- 1.80

VAS 15TH MIN

3.81 +- 2.18

3.82 +- 1.93

VAS 30TH MIN

2.46 +- 2.39

2.31 +- 1.96

>0.05

* Mann Whitney U test.

?? Friedman test.

30TH MIN 109.75 +- 14.91 85 108.64 +- 14.11 87 >0.05

p?? <0.001 0.006

0TH MIN

114.87 +- 20.70

88

113,34 +- 15.98

95

15TH MIN

111.75 +- 16.27

84

110.37 +- 15.33

88

* Mann Whitney U test.

?? Friedman test.

Table 3

Time-linked change in nausea VAS scores in groups.

VAS nausea

Dimenhydrinate

Metoclopramide

p?

scores

(n = 100)

(n = 100)

(mean +- SD)

VAS 0TH MIN

7.62 +- 1.48

7.45 +- 1.27

VAS 5TH MIN

5.78 +- 1.80

5.65 +- 2.07

VAS 15TH MIN

3.89 +- 2.29

3.93 +- 2.33

VAS 30TH MIN

p??

2.27 +- 2.24

<0.001

2.70 +- 2.48

<0.001

>0.05

* Mann Whitney U test.

?? Friedman test.

(p = 0.85). Also, nausea VAS changes at the 30th min. Were calculated as 5.39 +- 2.05 in the DMT group and 4.82 +- 2.23 in the MTP group (p = 0.06) (Table 4).

A statistically significant decrease was observed in mean systolic

Table 6

Fig. 2. Systolic blood pressure scores of groups.

blood pressure at 30th minute in both groups (p < 0.05). There was

Time-linked change in diastolic blood pressure scores in groups.

no statistically significant difference between the groups in terms of changes in mean systolic blood pressures at the 30th minute (p > 0.05, all) (Table 5, Fig. 2).

Diastolic blood pressure Dimenhydrinate

(n = 100)

Metoclopramide p?

(n = 100)

In the MTP group, a significant decrease was observed in mean dia- stolic blood pressure values at the 30th minute compared to the base- line (p < 0.001). At the same time, there was no significant difference in the DMT group at the 30th minute compared to the baseline (p = 0.07). There were no statistically significant differences between the groups in terms of changes in mean diastolic blood pressures at the 30th minute (p > 0.05, all) (Table 6, Fig. 3).

A statistically significant decrease was observed in heart rate scores at 30th minute in both groups (p < 0.05). There was no statistically sig- nificant difference between the groups in terms of changes in heart rate scores at the 30th minute (p > 0.05, all) (Table 7).

Out of 200 patients; 16.5% (n = 33) of patients stated sedation and 7% (n = 14) of patients stated hypotension, 1% (n = 2) stated fatigue and dyspepsia as side effects. There was no statistically significant dif- ference in adverse reactions between in group comparisons (Table 8). None of the hypotensive patients were symptomatic because concomittant heart rate levels of patients were stable in those BPs and none of the patients required treatment.

In total, 25 of the patients (25%) in the DMT group required rescue medication (14 of the patients required diazepam, 11 of the patient’s re- quired granisetron) and 23 of the patients (23%) in the MTP group

mean +- SD min. mean +- SD min.

0TH MIN 68.86 +- 11.65 52 69.68 +- 11.29 56

15TH MIN 67.69 +- 9.55 50 66.35 +- 9.18 53

30TH MIN 67.01 +- 10.33 51 66.08 +- 9.01 51 >0.05

p?? 0.07 <0.001

* Mann Whitney U test.

?? Friedman test.

required rescue medication (13 of the patients required diazepam, 10 of the patient’s required granisetron). None of the patients required a repeated dose, and no statistically significant difference was found re- garding the need for rescue treatment in both groups (p = 0.94).

  1. Discussion

In the present study, our purpose was to compare the effectiveness of DMT and MTP in patients who were admitted to the ED with nausea due to vertigo. Due to parenteral treatment efficacy, rapid relief, practi- cability for patients in the ED, we performed our study with intravenous administration, rather than choosing an oral treatment strategy.

Table 4

Treatment efficacy for groups.

Dimenhydrinate (n = 100)

Metoclopramide (n = 100)

p?

Nausea VAS changes 30th minute (mean +- SD)

5.39 +- 2.05

4.82 +- 2.23

0.06

Vertigo VAS changes 30th minute (mean +- SD)

5.14 +- 2.25

4.99 +- 2.20

0.85

* Mann Whitney U test.

Fig. 3. Diastolic blood pressure scores of groups.

Table 7

Metoclopramide is a common and inexpensive anti-emetic used for In-hospital treatment of nausea and vomiting [20], but there are only a few recent studies of MTP in motion sickness [27]. Rubio et al. con- ducted a study that compared the efficacy of intravenous MTP (50 mg), diphenhydramine (DPH), and placebo in patients with motion sickness [27]. The VAS score rate of motion sickness reduction in the MTP group was significantly higher than in the other two groups [27]. Most MTP and DMT combinations have been made about postoper- ative nausea and vomiting (PONV) treatment [18,28]. A randomized, double-blind study compared the anti-emetic efficacy of MTP alone, MTP and DMT combination in patients with PONV. It was revealed that the Combination therapy was better than MTP alone in reducing post-operative emesis intensity [28]. Eberhart et al. also compared the anti-emetic effectiveness of DMT and MTP in patients who had under- gone endonasal surgery. The ratio of patients free from PONV was 72.5% in the MTP group and 72.5% in the DMT group; the drug combina- tion group was higher than the monotherapy groups. The MTP and DMT combination was effective in reducing PONV [18]. When the literature is analyzed, MTP is frequently used as an antiemetic, it is inadequate as a

Time-linked change in heart rate scores in groups.

Heart rate scores

Dimenhydrinate

Metoclopramide

p?

(mean +- SD)

(n = 100)

(n = 100)

0TH MIN

79.25 +- 11.04

77.99 +- 10.44

15TH MIN

77.60 +- 10.41

76.15 +- 9.67

30TH MIN

75.35 +- 8.73

75.12 +- 8.82

>0.05

p??

<0.001

0.003

* Mann Whitney U test.

?? Friedman test.

Table 8

Comparison of adverse reactions in groups.

Dimenhydrinate (n = 100)

Metoclopramide p?

(n = 100)

monotherapy in PONV treatment, but its anti-emetic efficacy is high in combination with DMT [18,19,28]. In our study, we were unable to com- bine DMT and MTP drugs for ethical reasons.

Our study is one of the first to investigate the use of MTP in the treat- ment of vertigo. We found that MTP was at least as effective as DMT in relieving the symptoms of both vertigo and nausea. We believe that fur- ther randomized controlled multicenter combination studies are needed to support these findings.

In our study, we found a decrease in vertigo VAS scores in both the DMT and MTP groups at the 30th minute, but there was no significant difference between the groups when the vertigo VAS changes were compared; DMT and MTP were equally effective in the treatment of ver- tigo. Our results are similar to the study of Dogan et al. [6], but we think that the numerical difference in vertigo changes was due to the sample size, differences in the form of drug infusion, and different scales

Sedation n (%) 15(%15) 18(%18) >0,05

Hypotension n (%) 6(%6) 8(%8) >0,05

Other n (%) 0(%0) 2(%1) >0,05

* x2 test.

The present randomized, prospective, double-blind study shows that DMT and MTP are equally effective at reducing vertigo and fre- quently associated concomitant symptoms such as nausea. At the end of the 30th minute, at least 75% of patients’ vertigo and nausea VAS scores had fallen below 5 mm and they were discharged from the ED without the requirement of rescue medication.

With the use of dimenhydrinate in the treatment of peripheral ver- tigo, the symptoms of nausea and vertigo are reduced [18,19]. However, we determined that metoclopramide could be at least as effective as di- menhydrinate in vertigo and nausea symptoms, and this was one of the most important contributions of our study to the literature.

Dimenhydrinate has a general use as an anti-vertigo drug world- wide, and its efficacy has been shown in several clinical trials in patients with vertigo [3,6,15,17,26]. The results revealed that a combi- nation of DMT with other antivertigo drugs was more effective in re- ducing acute vertigo attacks, also a significant decrease was detected in vertigo-associated vegetative symptoms (nausea and vomiting) [16]. In our study, parallel with other studies [15,16], we think that di- menhydrinate is effective in reducing vertigo and nausea by pre- venting spreading impulses in the medullar vestibular nuclei, which are closely related to the vegetative regulator centers. Although we could not use a secondary drug combination with dimenhydrinate for ethical reasons, we achieved a significant decrease in both DMT and MTP monotherapy groups in vertigo VAS and nausea VAS scores in the 30th minute.

were used.

When the literature is examined, drowsiness and hypotension are common Adverse drug reactions of antihistaminics, and dry mouth and dizziness are also reported as adverse drug reactions of antiemetics [29,30]. In a randomized trial that used MTP in PONV, the authors re- vealed significant adverse reactions such as dry mouth (5.1%), dizziness (8.5%), and drowsiness (3.4%) [29]. In another study that used DMT, the most frequent adverse reaction was drowsiness (16.2%) [17]. In our study, we found that sedation was the most frequent adverse reaction (DMT 15%, MTP 18%, respectively), followed by hypotension (6% DMT, 8% MTP, respectively). This difference might be explained by our larger sample size and the different infusion strategies of the study drugs (30 min vs. 1 h).

According to our results, we found no statistically significant differ- ence regarding the need for rescue treatment in both groups. Irving et al. revealed that 45% of acute peripheral vertigo patients in the di- menhydrinate group and 42% of droperidol group felt well enough to go home 30th minutes after drug administration [3]. Also, Marill et al. reported that 86% of patients in the dimenhydrinate group and 69% in the lorazepam group were ready to go home at the 120th min after treatment. The DMT group’s home readiness scores were significantly higher than those of the lorazepam group [17]. In our study, 77% of pa- tients in the dimenhydrinate group and 75% of patients in the metoclopramide group needed no rescue medication and felt well enough to be discharged from the ED.

This study has several limitations that need to be addressed. We chose not to include a placebo arm in the study because some patients do not improve with placebo treatment; therefore, it would have been unethical to withhold medical treatment. Also, we could not include a combination group of DMT and MPT because ethics consultants consid- ered that combination therapies had no proven effects on nausea and vertigo symptoms. The third limitation is due to the high patient load

of our ED; we could not observe the patients for longer than 30 min. The fourth was not performing the canalith repositioning maneuver to pa- tients, which might have been effective in patients with vertigo. Also, we did not determine the level of minimal clinical important change for outcome measures because we could not find any from previous articles.

As a result, we think that the results of this study should be carefully reviewed and further studies may be performed with the inclusion of a placebo or combination treatment arm, which may help confirm the treatment of vertigo in the ED.

  1. Conclusion

In conclusion, this prospective, double-blind, randomized study showed that both DMT and MTP have similar efficacy in reducing nau- sea and vertigo symptoms in the ED.

Ethics ve funding source

Ethical approval (No: 2010:10-09/08/2012) was provided from In- stitutional review board of Pamukkale University Medical Faculty and

T.C. Ministry of Health, General Directorate of Pharmaceuticals and Pharmacy, Clinical Researches Department (No: 90837:31/08/2012).

This research supported by Pamukkale University Faculty of Medi- cine Research Fund, grant number (2012TPF034).

Declaration of Competing Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Acknowledgements

We would like to thank Ahmet Ergin, for his help in the analysis of statistical data.

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