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

Initial Workup and Management for Severe Vertigo

The initial workup for severe vertigo should include the HINTS examination (Head Impulse, Nystagmus, Test of Skew) to differentiate between peripheral and central causes, with immediate MRI indicated if central vertigo is suspected. 1, 2

Diagnostic Approach

Step 1: History Taking - Focus on:

• Duration of vertigo episodes:

  • Seconds: Suggests BPPV
  • 20 minutes to 24 hours: Consider Ménière's disease
  • Days: Consider vestibular neuronitis
  • Constant: Consider central cause

• Triggers:

  • Position changes: Suggests BPPV
  • No clear trigger: Consider vestibular neuronitis, Ménière's disease, or central causes

• Associated symptoms:

  • Hearing loss, tinnitus, ear fullness: Suggests Ménière's disease 3
  • Neurological symptoms (dysarthria, diplopia, numbness): Suggests central cause
  • Nausea/vomiting: Common with both peripheral and central causes

Step 2: Physical Examination

• HINTS examination (92.9% sensitivity, 83.4% specificity for central causes) 2:

  • Head Impulse Test: Abnormal (corrective saccade) suggests peripheral cause
  • Nystagmus: Direction-changing or vertical nystagmus suggests central cause
  • Test of Skew: Vertical misalignment suggests central cause

• Dix-Hallpike maneuver: Positive test (vertigo and characteristic nystagmus) confirms BPPV 3

• Supine roll test: For horizontal canal BPPV when Dix-Hallpike is negative 1

• Neurological examination: Assess for focal deficits (limb weakness, dysmetria, gait ataxia)

Step 3: Determine Peripheral vs. Central Cause

• Peripheral vertigo indicators:

  • Positive head impulse test
  • Unidirectional, horizontal nystagmus that lessens with fixation
  • No skew deviation
  • No neurological deficits

• Central vertigo indicators:

  • Normal head impulse test
  • Direction-changing, vertical, or pure torsional nystagmus
  • Skew deviation present
  • Neurological deficits present

Management Algorithm

For Peripheral Vertigo:

BPPV (most common):

1. Perform canalith repositioning procedure (Epley maneuver) with success rates of 61-95% after a single treatment 1
2. Alternative maneuvers include:
   • Semont maneuver
   • Gufoni maneuver
   • Lempert maneuver (for horizontal canal BPPV)
3. Repeat procedures can increase success to 90-98% 3
4. Follow-up within 1 month to assess resolution 1

Vestibular Neuronitis:

1. Symptomatic management with vestibular suppressants:
   • Meclizine 25-100 mg daily in divided doses 4
   • Diazepam 2-5 mg 1-3 times daily (short-term use only) 1
   • Prochlorperazine 25 mg for nausea/vomiting 1
2. Limit vestibular suppressant use to <1 week to avoid interference with vestibular compensation 1
3. Consider vestibular rehabilitation after acute phase

Ménière's Disease:

1. Diagnose based on:
   • Two or more episodes of vertigo lasting 20 minutes to 12 hours
   • Documented low to mid-frequency sensorineural hearing loss
   • Fluctuating aural symptoms (hearing loss, tinnitus, ear fullness) 3
2. Management:
   • Diuretics and/or betahistine to reduce symptoms or prevent attacks 1
   • Lifestyle modifications (sodium restriction, avoiding caffeine, alcohol, nicotine)
   • Vestibular suppressants during acute attacks

For Central Vertigo:

1. Immediate neuroimaging:
   • MRI brain with contrast is preferred over CT for better soft tissue resolution 3
   • MRI can detect inflammatory, infectious, demyelinating processes, and posterior circulation strokes 3
2. Neurology consultation
3. Supportive care while awaiting definitive diagnosis and treatment

Important Considerations

When to Obtain Imaging:

• Immediate imaging indicated for:

  • Abnormal HINTS examination suggesting central cause
  • Neurological deficits
  • First episode of severe vertigo in elderly or those with vascular risk factors
  • Atypical presentation or treatment failure

• Routine imaging is NOT indicated for:

  • Typical BPPV with positive Dix-Hallpike test and response to repositioning 3, 1

Medication Precautions:

• Vestibular suppressants (meclizine, diazepam):
  • Limit to short-term use (<1 week)
  • Warn patients about drowsiness and avoid driving/dangerous machinery 4
  • Avoid alcohol while taking these medications 4
  • Use lower doses (2 mg diazepam) in elderly patients 1
  • Use with caution in patients with asthma, glaucoma, or prostate enlargement 4

Red Flags Requiring Urgent Evaluation:

• New-onset severe headache
• Vertical or direction-changing nystagmus
• Skew deviation
• Normal head impulse test with acute severe vertigo
• Any focal neurological deficits
• Sudden hearing loss

By following this systematic approach, clinicians can efficiently diagnose the cause of severe vertigo and initiate appropriate management while identifying patients who require urgent neuroimaging and specialist referral.