Vertigo: The Dizzying Effects of Benzodiazepine Withdrawal

Is vertigo a recognized symptom of benzodiazepine withdrawal?

Yes. Dizziness, light-headedness, and poor balance sit together on one line of Table 1 in Chapter III of the Ashton Manual, the list of benzodiazepine withdrawal symptoms compiled by Professor C. Heather Ashton. It is a known part of withdrawal, and it is frightening when no one has warned the patient that it can happen.

Those words cover three different sensations. Vertigo, the most alarming kind of dizziness, is a false sense of motion, the room turning or the floor tilting when nothing is moving. Light-headedness is the faint, floating feeling that often comes with standing up, and poor balance is plain unsteadiness on the feet.

Professor Ashton described the unsteadiness and the spinning in her own words. In the same chapter, she wrote that some people in withdrawal “report feeling unsteady on their feet,” and that sometimes “they feel they are being pushed to one side or feel giddy, as if things were going round and round.” Patients who are tapering today use nearly the same words. So, why would a lower dose of a calming medication make the room move?

Why does lowering the dose unsettle balance?

Benzodiazepines strengthen the effect of gamma-aminobutyric acid (GABA), the main calming chemical messenger of the nervous system. Over months or years of steady use, the brain adapts to that extra calming signal, and its receptors become less responsive. When the dose drops, the adapted nervous system is left with less calming than it has come to expect.

Chapter III of the Manual describes what happens next, and a separate article covers what happens in the brain during benzodiazepine withdrawal in more detail. Until new adaptations develop, Professor Ashton wrote, “the brain and peripheral nervous system are in a hyperexcitable state.” In plain words, nerves fire too easily, and that likely includes the ones that tell the brain where the body is in space.

She also pointed to one structure in particular. The cerebellum, the part of the brain that keeps a person steady, is in her words “densely packed with GABA and benzodiazepine receptors.” Too much benzodiazepine makes a person unsteady, and a falling dose can do the same for a while.

A person who steps onto a dock after several days on a boat knows a version of this. The ground is still, yet the body keeps correcting for waves that are no longer there. While this is not a perfect comparison, the lesson holds. The balance system was tuned to the sea, and it needs time on land to tune itself back.

A patient whose balance falters when a prescribed dose is lowered is in the same position. The nervous system adapted to a medication that a doctor prescribed. That is physical dependence, and dependence is not addiction. Unfortunately, the wrong label is still applied to patients whose only problem is a nervous system adjusting to a lower dose.

Does the dizziness go away?

In the Manual’s account, it does. Professor Ashton wrote that it “may take some time for the cerebellar systems to restabilise after benzodiazepine withdrawal and the symptoms can last until this process is complete.” She treated poor balance as a temporary state of a nervous system that is still adapting.

It does not fade in a straight line. Chapter III notes that withdrawal symptoms “characteristically wax and wane,” changing from day to day and even within a single day. So, a bad week of vertigo after a good one does not mean that the taper has failed.

No one can promise a date. The honest answer is that the dizziness tends to ease as the taper proceeds and the nervous system catches up with each new dose, and that the pace differs from person to person. In the same chapter, Professor Ashton stressed that withdrawal symptoms “can be minimised and largely avoided by slow tapering.”

A surge of dizziness after a cut means the cut was too large.

Dizziness that surges in the days after a dose reduction is information. It says that the step down was more than the nervous system could absorb at that moment. It is not a reason to push through, and it is not a reason to speed up and get the taper over with.

One answer is a short hold, though everybody is different, and some patients do better continuing at a steady pace than waiting out a long hold, with any change planned with the prescriber and the medication never stopped suddenly. Chapter II of the Manual advises that a person who reaches a difficult point can stay at that dose for a few weeks, and it leaves the pace to the patient. The next reduction can then be smaller.

Fortunately, this is the part that a patient and a physician can control. A gradual, medically supervised taper over months gives the balance system time to keep up. The Manual suggests steps of up to one tenth of the dose, and the Maudsley Deprescribing Guidelines describe hyperbolic tapering, in which each cut is sized to the dose that remains, so the cuts get smaller as the dose gets lower.

The opposite approach is the dangerous one. In its 2020 update to the benzodiazepine boxed warning, the United States Food and Drug Administration (FDA) said that stopping abruptly or reducing the dosage too quickly can result in withdrawal reactions, including seizures, which can be life-threatening. A seizure, or any other medical emergency, is a reason to call 911 right away.

What helps on a dizzy day?

The first job is to prevent a fall. Rising slowly helps, which means sitting on the edge of the bed for a moment before standing, and standing still for a moment before walking. A light left on at night, a hand on the stair rail, clear floors, and no ladders are plain precautions that cost nothing.

Driving needs the same caution. A person who is having vertigo or feels faint should not drive or operate machinery until the spell has fully passed. A person whose spells arrive without warning should talk with their physician before driving at all.

Older patients have the most to lose from a fall. Chapter II notes that older people can withdraw as successfully as younger people, and it lists falls and fractures among the compelling reasons for them to come off these drugs.

For balance itself, the Manual suggests practice. Professor Ashton recommended exercises such as standing on one leg, first with the eyes open and then with them closed, and wrote that they can speed the return of steadiness. A kitchen counter or a sturdy chair within reach makes that safe to try.

Ordinary hydration matters, because a person who is short on fluids gets light-headed on standing for that reason alone. The Manual sees no need for extra fluid beyond that.

Alcohol unsteadies anyone, and it acts on the same GABA system as a benzodiazepine. A person who is already dizzy has good reason to leave it alone.

Caffeine is more individual. While the Manual considers coffee or tea in moderation compatible with withdrawal, a person who finds that caffeine worsens the light-headedness can cut back and judge by the result.

What about medication for the dizziness?

Motion sickness and anti-nausea medicines are often suggested for vertigo. For the poor balance of withdrawal, the Manual offers exercises and time. It does not offer another drug.

Many of those medicines are sedating, and a sedated person is no steadier on their feet. The evidence for any of them in benzodiazepine withdrawal is limited, individual response varies, and the decision belongs to the individual patient and a physician who understands the pharmacology. The same is true of supplements and other remedies promoted for dizziness, and none of them is a substitute for a gradual taper.

When is dizziness an emergency?

Not every dizzy spell during a taper is withdrawal. Sudden, severe vertigo that arrives with a drooping face, weakness or numbness on one side, slurred speech, double vision, a severe headache, or an inability to walk can be a stroke. That is a call to 911. It is never a symptom to wait out.

The same goes for dizziness with chest pain, trouble breathing, fainting or loss of consciousness, or a fall with a head injury or a possible broken bone. Emergency care comes first. The question of what caused it can be answered afterward.

Dizziness that is new, different from the usual pattern, or paired with hearing loss deserves a visit with the patient’s own physician as well. Inner ear conditions, blood pressure changes, and other medications all cause dizziness. A taper does not protect anyone from them.

What else do patients ask about dizziness during a taper?

Can dizziness come on between doses, without any dose cut?

It can, especially with short-acting benzodiazepines. Chapter II of the Manual explains that with drugs such as alprazolam (Xanax) and lorazepam (Ativan), levels rise and fall between doses, and a person can feel withdrawal before the next dose is due. This is known as interdose withdrawal. For these drugs, the Manual advises a crossover taper to long-acting diazepam (Valium). The crossover taper is used where it helps, and it is not a rule for everyone.

Is the unsteadiness from withdrawal or from the medication itself?

It can be either. The Manual points out that excessive doses of benzodiazepines cause unsteadiness of gait and general incoordination, so too much of the drug and too little can both disturb balance. Timing is often the clue. Unsteadiness that follows a dose points one way, and unsteadiness that follows a cut, or arrives before the next dose is due, points the other.

A slow, supervised taper gives balance time to return.

Dr. Mark Leeds is an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida. He is one physician who works directly with each patient, and his practice’s primary service is medically supervised benzodiazepine and z-drug tapering for patients in Florida.

In his practice, a patient who reports a surge of vertigo after a reduction is not told to tough it out. The pace is looked at together, a short hold or a smaller next step for some and a steady pace for others, and the medication is never stopped suddenly. While Professor Ashton preferred a hold to any increase, Dr. Leeds regards a small step back up as a legitimate choice when a cut has plainly proved too large.

In Dr. Leeds’ practice, another medication is not the first answer to withdrawal dizziness, and any decision of that kind is made with the individual patient. The taper itself is the treatment, gradual and directed by the patient, and with time steadiness tends to return. Contact the office to ask about a supervised taper.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.