What is the appropriate management for a patient presenting with acute vestibular syndrome, including workup for stroke and treatment options for vestibular neuritis, benign paroxysmal positional vertigo, Ménière’s disease, vestibular migraine, and chronic dizziness?

Management of Acute Vestibular Syndrome and Vestibular Disorders

For acute vestibular syndrome, immediately perform the HINTS Plus examination (Head Impulse, Nystagmus, Test of Skew, plus hearing assessment) to differentiate stroke from peripheral causes—this bedside exam is more sensitive and specific than early MRI for posterior circulation stroke 1, 2.

Initial Approach: Timing and Triggers Classification

Classify patients into one of four vestibular syndromes based on symptom timing 3:

• Acute Vestibular Syndrome (AVS): Continuous dizziness lasting days to weeks with nausea, vomiting, intolerance to head motion
• Triggered Episodic: Brief episodes (<1 minute) provoked by specific head positions
• Spontaneous Episodic: Episodes lasting minutes to hours without triggers
• Chronic: Dizziness lasting weeks to months

This framework immediately narrows your differential and determines which bedside tests to perform.

Acute Vestibular Syndrome (AVS) Management

Stroke Workup

Critical red flags requiring immediate stroke evaluation 3:

• Downbeating nystagmus on Dix-Hallpike (especially without torsional component)
• Direction-changing nystagmus without head position changes
• Gaze-evoked nystagmus
• Dysarthria, dysmetria, dysphagia, sensory/motor deficits, or Horner's syndrome
• Severe gait instability with inability to walk

HINTS Plus examination components 1, 2:

1. Head Impulse Test: Normal (corrective saccade absent) = central cause likely
2. Nystagmus: Direction-changing or purely vertical = central
3. Test of Skew: Vertical misalignment = central
4. Plus (Hearing): Acute hearing loss = consider labyrinthine stroke

One abnormal central finding on HINTS Plus indicates stroke until proven otherwise—do NOT wait for MRI 1. MRI with diffusion-weighted imaging has false-negative rates up to 20% (even 50% for small brainstem strokes) in the first 48 hours 4, 5.

Vestibular Neuritis Treatment

For peripheral AVS (vestibular neuritis) with reassuring HINTS Plus 6, 1:

Acute phase (first 3-5 days):

• Vestibular suppressants (meclizine, diazepam) for severe nausea/vomiting ONLY during the first 3 days 7
• Do NOT continue vestibular suppressants beyond 3-5 days—they impair central compensation 7

Recovery phase (after acute symptoms):

• Vestibular rehabilitation is the primary treatment—start as soon as tolerated 1, 8
• Physical therapy accelerates recovery and prevents chronic dizziness

Benign Paroxysmal Positional Vertigo (BPPV)

Diagnosis

Perform Dix-Hallpike maneuver: Bring patient from upright to supine with head turned 45° to one side and neck extended 20°, affected ear down 3. Positive test shows torsional upbeating nystagmus with vertigo.

If Dix-Hallpike shows horizontal or no nystagmus, perform supine roll test for lateral canal BPPV 3.

Treatment

Canalith repositioning procedure (Epley maneuver) is the primary treatment for posterior canal BPPV—this is a strong recommendation 3. Success rates are 4.1 times higher than observation at 1 month 7.

Do NOT recommend post-procedural positional restrictions—they provide no benefit 3.

Do NOT routinely prescribe vestibular suppressants for BPPV—they are ineffective as primary treatment 3, 7. Use only for severe nausea if needed.

Observation is an option for patients who decline repositioning, but inform them of longer symptom duration and higher recurrence rates 7.

Follow-up

Reassess within 1 month to document resolution or persistence 3. If symptoms persist, re-evaluate for unresolved BPPV or alternative diagnoses 3.

Ménière's Disease

Diagnosis

Requires episodic vertigo attacks (lasting 20 minutes to 12 hours) with 6:

• Fluctuating sensorineural hearing loss
• Tinnitus
• Aural fullness in the affected ear

Obtain audiogram when assessing for Ménière's disease 6.

Do NOT routinely order vestibular function testing or electrocochleography—clinical diagnosis is sufficient 6.

Treatment Algorithm

Step 1: Conservative management 6:

• Patient education about natural history
• Salt restriction
• Diuretics (though evidence is limited)
• Limited course of vestibular suppressants for acute attacks only

Step 2: Intratympanic steroids for active disease not controlled with conservative measures 6

Step 3: Intratympanic gentamicin for active disease unresponsive to non-ablative therapy 6

Step 4: Surgical ablative therapy for patients with failed medical management and non-usable hearing 6

Do NOT prescribe positive pressure therapy (Meniett device)—guideline recommends against it 6.

Vestibular Migraine

Diagnosis Criteria 3:

• ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours
• Current or history of migraine (International Headache Society criteria)
• ≥1 migraine symptom during at least 50% of dizzy episodes (migrainous headache, photophobia, phonophobia, visual aura)
• Other causes ruled out

Key distinguishing features from Ménière's: Episodes may be shorter or longer than Ménière's, hearing loss less likely, more photophobia than visual aura 6.

Treatment

Focus on migraine prophylaxis (though specific medications not detailed in guidelines). Vestibular rehabilitation may help with chronic symptoms 3.

Chronic Dizziness Management

Vestibular rehabilitation is the cornerstone for chronic vestibular symptoms regardless of etiology 1, 8.

Assess fall risk in all patients, especially elderly 3:

• 9% of geriatric patients have undiagnosed BPPV
• Three-fourths of elderly with BPPV had fallen within 3 months 3
• Evaluate mobility, balance, CNS disorders, home support 3

Common Pitfalls to Avoid

1. Relying on early MRI alone in AVS—HINTS Plus is more sensitive for stroke in first 48 hours 1, 5
2. Prescribing vestibular suppressants long-term—they impair compensation and prolong recovery 7
3. Ordering unnecessary imaging for typical BPPV—do not obtain imaging when diagnostic criteria are met without additional concerning signs 3
4. Missing stroke in elderly patients—10% of cerebellar strokes present like peripheral vestibular disorders 3
5. Failing to reassess treatment failures—persistent symptoms warrant re-evaluation for alternative diagnoses 3