Jack E. Fincham, PhD, RPh
Jack E. Fincham, PhD, clinical pharmacy faculty affiliate in the Osher Lifelong Learning Institute, University of Arizona, Tucson. OLLI.Arizona.edu
Read the package insert for any medication and you’ll likely see dizziness listed as a possible side effect. Still, few of us take dizziness seriously. But we should. Dizziness can lead to a fall…and that could lead to a serious injury.
More than half of all Americans are taking two prescription medications—20% are taking five or more, according to Mayo Clinic research. So it’s important to recognize that side effects, including dizziness, are more pronounced with every drug you take. The increased effects are not additive—they are exponential. After a while, the question is not if you will fall, but when. Falls are one of the leading causes of long-term disability in older adults.
Here are widely used medications that commonly cause dizziness and falls. Chances are you use at least one of the following medications.
The risks of opioid pain medications (including disorientation and dizziness) are well-known, but there is an increased fall risk even with over-the-counter (OTC) pain relievers. These seemingly benign medications influence many body systems, including the central nervous system (CNS), and can cause dizziness, even at normal doses. Examples: Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil) and naproxen (Aleve).
Surprisingly, aspirin may be the worst offender. In addition to its effects on the CNS, aspirin bombards the vestibular nerve that feeds balance information from the inner ear to the brain. Many people can’t take aspirin (even the baby aspirin dose of 81 mg) without experiencing severe dizziness or even vertigo—the nauseating perception that the room is spinning or tilting.
Note: Muscle relaxers are also sometimes prescribed for pain. These drugs cause significant drowsiness. Examples: Carisoprodol (Soma), cyclobenzaprine (Flexeril) and orphenadrine (Norflex). When paired with a pain reliever, the combination of dizziness and drowsiness is a perfect recipe for a fall.
Diphenhydramine is an antihistamine recommended to clear a stuffy nose and induce drowsiness at bedtime. Examples: Benadryl, Tylenol PM, Advil PM and Aleve PM.
Like aspirin, diphenhydramine affects the CNS and the vestibular system, causing dizziness. It also slows down mental abilities such as thinking and processing information, so you may be less able to recognize side effects.
Because this drug is included in medications as a sleep aid, many people assume that they can sleep away the side effects. But diphenhydramine has a long half-life—in older adults, it can stay in their systems for up to 18 hours. The medication-induced dizziness can cause a fall if you get up during the night, for example, to use the bathroom.
All antidepressants work at the level of neurotransmitters—the chemical messengers, such as serotonin, norepinephrine and dopamine, that allow us to think, act and experience emotion.
The most widely used antidepressants are selective serotonin reuptake inhibitors (SSRIs), which work by making serotonin more available to the brain, elevating mood and decreasing anxiety. Examples: Fluoxetine (Prozac), paroxetine (Paxil) and sertraline (Zoloft).
Migraine drugs also work by affecting serotonin availability. Examples: Sumatriptan (Imitrex) and zolmitriptan (Zomig).
Serotonin and norepinephrine reuptake inhibitors (SNRIs) are a newer type of antidepressant that makes both serotonin and norepinephrine more available to the brain. Examples: Duloxetine (Cymbalta), venlafaxine (Effexor) and desvenlafaxine (Pristiq).
Bupropion (Wellbutrin) affects the availability of both norepinephrine and dopamine. Note: The smoking-cessation medication Zyban also contains bupropion.
Besides affecting mood, these antidepressants carry messages to the brain from the balance centers of the inner ear, so they can affect your equilibrium. In addition, a faulty message can make the communication between brain and body less responsive. When you stand up or move, you may be less able to control your body position, increasing the risk of toppling over.
Over-the-counter drugs such as dimenhydrinate (Dramamine) and meclizine (Bonine) used to prevent nausea, vertigo, dizziness and car sickness also can induce dizziness on their own.
There are many types of blood pressure medications, including…
• Diuretics (“water pills”), such as furosemide (Lasix) and hydrochlorothiazide (Microzide).
• Beta-blockers, such as propranolol (Inderal) and atenolol (Tenormin).
• Angiotensin-converting enzyme (ACE) inhibitors, such as enalapril (Vasotec) and lisinopril (Zestril).
• Angiotensin II receptor blockers (ARBs), such as losartan (Cozaar) and olmesartan (Benicar).
• Calcium channel blockers, such as amlodipine (Norvasc).
All medications that lower your blood pressure can also diminish your ability to quickly adapt to changing blood pressure needs, such as when you change your body position. Therefore, a common side effect of these drugs is orthostatic hypotension—a sudden spell of light-headed dizziness that happens when you quickly stand up after sitting or lying down.
Drugs for epilepsy, fibromyalgia and neuropathy can alleviate pain by putting the brakes on nerve impulse transmission. But this may limit the brain’s ability to respond normally and quickly, significantly reducing alertness and increasing dizziness. Examples: Gabapentin (Neurontin), pregabalin (Lyrica) and carbamazepine (Tegretol), all commonly used to treat diabetic nerve pain and fibromyalgia…and clonazepam (Klonopin) and phenytoin (Dilantin), both used as antiepileptic drugs.
Ginkgo biloba is an herbal product used to treat altitude sickness, dizziness and vertigo. It, too, can cause dizziness by itself.
Literally every drug has the potential to cause dizziness and increase your risk of falling. What to do…
• For occasional-use medications —assess your level of discomfort. If you don’t really need a drug, don’t take it. If you must take a medication, develop an alternate plan that may include a medication change that is approved after consultation with your health-care provider.
• For long-term medications— never stop taking them without advice from your health-care provider. Many medications need to be tapered and will create rebound side effects if stopped abruptly.
• For all new medications—be alert for signs of dizziness or drowsiness. Are your body and mind as quick and responsive as usual? Do you feel alert? These side effects may be subtle or pronounced, but they should not be ignored. If they occur, avoid any activity that could result in a fall, including using stairs or ladders. If you must use stairs, steady yourself with handrails and move slowly up or down the stairs.
As your body adjusts to a medication, you may be prescribed a higher dosage to get the appropriate therapeutic effect. Important: Watch for new side effects with each dosage change. They can appear even after the drug has been taken for an extended period.
• If you experience orthostatic hypotension—be sure to take your time standing up…and don’t immediately start walking. Take a moment to steady yourself. If you become light-headed, sit down immediately. This practice is useful for anyone taking medication.
• If you feel dizzy or have other troubling side effects while using any medication—call your doctor…or talk to your pharmacist, who may be more accessible. Ask if there is another treatment that might have fewer side effects and less dizziness.
• Before driving or exercising— observe how you are reacting to the medication. Does an effect diminish in intensity after a while? If so, try to drive small distances and exercise carefully with companions to see how you are doing.
