What is the initial workup and management for a patient presenting with vertigo?

Initial Workup and Management for Vertigo

The initial workup for vertigo should include the Dix-Hallpike maneuver to diagnose posterior semicircular canal BPPV, followed by a supine roll test if the Dix-Hallpike is negative or shows horizontal nystagmus, as these tests can immediately identify the most common cause of vertigo and guide appropriate treatment. 1

Diagnostic Approach

Step 1: History Taking - Focus on Vertigo Characteristics

• Duration of episodes:
  • Seconds (suggests BPPV)
  • 20 minutes to 12 hours (suggests Ménière's disease)
  • Days (suggests vestibular neuritis)
  • Constant (suggests central cause)
• Triggers:
  • Positional changes (suggests BPPV)
  • Spontaneous episodes (suggests Ménière's or vestibular neuritis)
• Associated symptoms:
  • Hearing loss, tinnitus, aural fullness (suggests Ménière's disease) 1
  • Headache, photophobia (suggests vestibular migraine)
  • Neurological symptoms (suggests central cause)

Step 2: Physical Examination - Key Maneuvers

1. Dix-Hallpike maneuver (gold standard for posterior canal BPPV diagnosis):

   • Position patient from upright to supine with head turned 45° to one side and neck extended 20°
   • Observe for torsional, upbeating nystagmus
   • Repeat with opposite ear down if initial test negative 1

2. Supine roll test (for lateral canal BPPV):

   • Perform if Dix-Hallpike is negative or shows horizontal nystagmus
   • Roll patient's head 90° to each side while supine
   • Observe for horizontal nystagmus 1

3. HINTS examination (for acute vestibular syndrome):

   • Head Impulse test
   • Nystagmus evaluation
   • Test of Skew
   • When performed by trained practitioners, more sensitive than early MRI for detecting stroke (100% vs 46%) 1

Management Algorithm

For BPPV (most common cause):

1. First-line: Canalith Repositioning Procedure (CRP)

   • For posterior canal BPPV: Epley maneuver
   • For lateral canal BPPV: Lempert roll or Gufoni maneuver
   • Success rate reaches 90-98% when additional repositioning maneuvers are performed 1
   • No postprocedural restrictions necessary 1

2. Second-line options:

   • Vestibular rehabilitation (either self-administered or clinician-guided) 1
   • Observation with follow-up (spontaneous resolution may occur) 1

3. Avoid: Vestibular suppressant medications (antihistamines, benzodiazepines) should not be routinely used 1

For Acute Vestibular Syndrome (persistent vertigo):

1. If HINTS exam suggests peripheral cause:

   • Consider symptomatic treatment with meclizine 25-100mg daily in divided doses 2
   • Caution: meclizine causes drowsiness; avoid driving and alcohol 2

2. If HINTS exam suggests central cause or is inconclusive:

   • Urgent neuroimaging (MRI preferred over CT for posterior circulation) 1
   • Neurological consultation

Follow-up and Treatment Failure

• Reassess all patients within 1 month to document resolution or persistence 1
• For persistent symptoms, evaluate for:
  1. Unresolved BPPV (may require repeat CRP)
  2. Involvement of different semicircular canals
  3. Other peripheral vestibular disorders
  4. Central nervous system disorders (found in 3% of BPPV treatment failures) 1

Important Caveats

• Avoid unnecessary imaging: Do not obtain radiographic imaging or vestibular testing in patients who meet diagnostic criteria for BPPV without additional concerning symptoms 1

• Red flags requiring further workup:

  • Neurological symptoms (dysarthria, diplopia, ataxia)
  • New-onset headache
  • Vertical nystagmus that doesn't lessen with fixation
  • Failed response to appropriate repositioning maneuvers
  • Risk factors for cerebrovascular disease

• Patient education: Counsel patients about safety concerns, fall risk, potential for recurrence, and importance of follow-up 1

By following this systematic approach to vertigo evaluation and management, clinicians can efficiently diagnose and treat the most common causes while identifying patients who need further workup for more serious conditions.