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

Initial Management of Episodic Vertigo

The initial management of episodic vertigo should focus on determining the specific vestibular syndrome through timing and triggers assessment, followed by targeted physical examination maneuvers like the Dix-Hallpike test to distinguish between peripheral and central causes.

Diagnostic Approach

Step 1: Categorize the Vertigo by Timing and Triggers

Categorizing vertigo by timing and triggers is more useful than focusing on symptom quality 1:

• Triggered Episodic Vestibular Syndrome:

  • Brief episodes triggered by specific actions (typically position changes)
  • Episodes usually last <1 minute
  • Common cause: Benign Paroxysmal Positional Vertigo (BPPV)

• Spontaneous Episodic Vestibular Syndrome:

  • Episodes not triggered by specific actions
  • Episodes last minutes to hours
  • Common causes: Vestibular migraine, Ménière's disease, TIA

• Acute Vestibular Syndrome:

  • Continuous dizziness lasting days to weeks
  • Associated with nausea, vomiting, head motion intolerance
  • Common causes: Vestibular neuritis, labyrinthitis, posterior circulation stroke

• Chronic Vestibular Syndrome:

  • Dizziness lasting weeks to months
  • Common causes: Anxiety, medication side effects, posterior fossa masses

Step 2: Perform Targeted Physical Examination

For Suspected BPPV:

• Perform the Dix-Hallpike maneuver for posterior canal BPPV 2, 1
• Look for:
  • Delayed onset of vertigo and nystagmus after position change
  • Upbeating and torsional nystagmus lasting <60 seconds
  • Symptoms that fatigue with repeated testing

For Suspected Central Causes:

• Perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) 1
  • Abnormal Head-Impulse and unidirectional nystagmus suggest peripheral causes
  • Normal Head-Impulse and direction-changing nystagmus suggest central causes
  • HINTS has 92.9% sensitivity and 83.4% specificity for central causes
  • HINTS+ (adds hearing assessment) increases sensitivity to 99%

Step 3: Consider Common Diagnoses Based on Presentation

BPPV (most common cause):

• Diagnostic criteria 2:
  • Positional vertigo lasting less than a minute
  • Not associated with hearing loss, tinnitus, or aural fullness
  • Positive Dix-Hallpike test

Ménière's Disease:

• Diagnostic criteria 2:
  • Two or more spontaneous attacks of vertigo lasting 20 minutes to 12 hours
  • Fluctuating aural symptoms (hearing loss, tinnitus, fullness) in the affected ear
  • Audiometrically documented low-to-midfrequency sensorineural hearing loss

Vestibular Migraine:

• Diagnostic criteria 2:
  • ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours
  • Current or history of migraine
  • ≥1 migraine symptoms during at least 50% of dizzy episodes

Initial Management Based on Diagnosis

For BPPV:

1. Perform Canalith Repositioning Procedures (CRP) 2, 1:

   • Epley maneuver for posterior canal BPPV
   • Modified Epley or Gufoni maneuver for lateral canal BPPV

2. Patient Education:

   • Counsel regarding fall risk, especially in elderly patients 2
   • Inform about recurrence rates (15% per year, up to 50% at 5 years) 1

For Ménière's Disease:

1. Symptomatic Management:
   • Low-salt diet
   • Diuretics
   • Vestibular suppressants during acute attacks 1

For Vestibular Migraine:

1. Lifestyle Modifications:
   • Migraine triggers avoidance
   • Regular sleep schedule

For Symptomatic Relief (Across Diagnoses):

1. Vestibular Suppressants (short-term use only):
   • Meclizine 25-100 mg daily in divided doses 3
   • Caution: May cause drowsiness; patients should avoid driving and alcohol 3

Imaging Considerations

• No imaging is typically needed for typical BPPV with positive Dix-Hallpike test 1

• Consider MRI head without IV contrast for:

  • Abnormal HINTS exam
  • Neurological deficits
  • High vascular risk patients 1

• Consider CT head without IV contrast when MRI is not immediately available for high-risk patients 1

Red Flags Requiring Urgent Evaluation

• Direction-changing nystagmus without changes in head position
• Downbeating nystagmus on Dix-Hallpike (particularly without torsional component)
• Baseline nystagmus without provocative maneuvers
• Failure to respond to appropriate repositioning maneuvers 2
• Associated neurological symptoms or signs
• Posterior circulation stroke can present with isolated dizziness in up to 25% of cases (75% in high vascular risk patients) 1

Common Pitfalls to Avoid

• Relying solely on symptom quality descriptions (vertigo, lightheadedness) as these are often unreliable 1
• Missing central causes of vertigo that can mimic peripheral causes
• Prolonged use of vestibular suppressants, which can delay central compensation
• Failing to reassess patients who don't respond to initial treatment

Remember that loss of consciousness is never a symptom of Ménière's disease, which can help distinguish it from other causes of dizziness 1.