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

Initial Management of Vertigo

The initial management of vertigo should focus on determining whether the cause is peripheral or central, with canalith repositioning procedures (CRPs) such as the Epley maneuver being the first-line treatment for benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo. 1

Diagnostic Approach

Step 1: Classify the Vertigo by Timing and Triggers

• Episodic triggered vertigo: Provoked by specific head movements (suggests BPPV)
• Acute persistent vertigo: Continuous vertigo lasting hours to days (suggests vestibular neuritis, labyrinthitis, or stroke)
• Episodic spontaneous vertigo: Recurring attacks without clear triggers (suggests Menière's disease)

Step 2: Perform Key Diagnostic Tests

1. Dix-Hallpike maneuver: To diagnose posterior canal BPPV

   • Positive: Vertigo with torsional, upbeating nystagmus
   • If negative or shows horizontal nystagmus, perform supine roll test for lateral canal BPPV 1

2. HINTS examination (for acute persistent vertigo):

   • Head-Impulse test
   • Nystagmus evaluation
   • Test of Skew
   • A normal HINTS exam consistent with peripheral vertigo suggests vestibular neuritis or labyrinthitis 2
   • Abnormal HINTS exam suggests central cause requiring urgent evaluation

Step 3: Determine Peripheral vs. Central Cause

• Peripheral causes (more common, generally benign):

  • BPPV, vestibular neuritis, Menière's disease, labyrinthitis
  • Characteristics: Horizontal nystagmus that lessens with visual fixation, no other neurological symptoms

• Central causes (less common, potentially serious):

  • Stroke, multiple sclerosis, tumors
  • Characteristics: Nystagmus that doesn't lessen with fixation, associated neurological symptoms 3

Treatment Algorithm

For BPPV (most common cause):

1. First-line treatment: Canalith repositioning procedures

   • Posterior canal BPPV: Epley maneuver (90.7-96% success rate) 1
   • Lateral canal BPPV: Gufoni maneuver (93% success rate) or Barbecue Roll maneuver (75-90% effectiveness) 1

2. Follow-up: Reassess within 1 month to confirm symptom resolution 1

   • If symptoms persist, re-evaluate diagnosis and repeat appropriate repositioning maneuver

For Vestibular Neuritis/Labyrinthitis:

1. Symptomatic treatment: Short-term vestibular suppressants (≤1 week)

   • Meclizine 25-100 mg daily in divided doses 4
   • Caution: May cause drowsiness; patients should avoid driving and alcohol 4

2. Antiemetics for nausea/vomiting:

   • Prokinetic antiemetics like metoclopramide or domperidone 1

3. Vestibular rehabilitation: To promote central compensation 1

For Acute Persistent Vertigo with Suspected Central Cause:

1. Urgent neuroimaging:
   • MRI head without and with IV contrast is preferred 2
   • CT head has limited value in detecting posterior fossa lesions 2

Important Cautions and Pitfalls

1. Avoid prolonged use of vestibular suppressants:

   • The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends against routine treatment of BPPV with vestibular suppressant medications 1
   • Limit use to <1 week to avoid interference with vestibular compensation 1

2. Don't miss central causes:

   • Up to 11% of patients presenting with acute persistent vertigo but no focal neurologic symptoms may have an acute infarct 2
   • Posterior circulation strokes can present with isolated vertigo in 25-75% of cases 2

3. Medication considerations:

   • Use meclizine with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 4
   • Avoid concurrent use with other CNS depressants and alcohol 4

4. Patient safety:

   • Educate patients about fall prevention
   • Advise about potential for disease recurrence (approximately 36%) 1
   • Recommend keeping a symptom journal to track triggers and patterns 1

By following this structured approach to the initial management of vertigo, clinicians can effectively diagnose the cause, provide appropriate treatment, and identify patients requiring further evaluation for potentially serious conditions.