What is the initial workup and treatment for a patient presenting with dizziness that has a positional component?

Initial Workup and Treatment for Positional Dizziness

For patients presenting with dizziness that has a positional component, clinicians should first perform the Dix-Hallpike maneuver to diagnose posterior semicircular canal BPPV, and if negative or showing horizontal nystagmus, perform a supine roll test to assess for lateral semicircular canal BPPV. 1, 2

Diagnostic Approach

Step 1: Focused History

• Determine timing and triggers of dizziness episodes:
  • Episodic triggered by position changes: Suggests BPPV
  • Spontaneous episodes with associated symptoms: Consider vestibular migraine or TIA
  • Acute constant dizziness: Consider vestibular neuritis or stroke 3
• Document specific head positions that provoke symptoms
• Note duration of each episode (BPPV typically lasts seconds to minutes)
• Assess for associated symptoms (hearing loss, tinnitus, neurological symptoms)

Step 2: Physical Examination

1. Dix-Hallpike Maneuver (for posterior canal BPPV):

   • Position patient upright, turn head 45° to one side
   • Rapidly move patient to supine position with head extended 20° over edge of table
   • Observe for torsional, upbeating nystagmus (indicates posterior canal BPPV)
   • Repeat on opposite side if initial test negative 1

2. Supine Roll Test (for lateral canal BPPV):

   • If Dix-Hallpike is negative or shows horizontal nystagmus
   • Position patient supine with head in neutral position
   • Quickly turn head 90° to one side, then the other
   • Observe for horizontal nystagmus 1, 2

3. Additional Assessment:

   • Evaluate for balance impairment and fall risk
   • Perform neurological examination to rule out central causes
   • Assess for signs of central nervous system disorders 1, 2

Step 3: Avoid Unnecessary Testing

• Do not order radiographic imaging for patients meeting diagnostic criteria for BPPV without additional concerning signs/symptoms 1
• Do not order vestibular testing for straightforward BPPV cases 1
• Consider additional testing only if:
  • Atypical presentation
  • Neurological signs present
  • Failed treatment response
  • Recurrent symptoms 2

Treatment Algorithm

For Posterior Canal BPPV (most common, ~85-95% of cases):

1. Canalith Repositioning Procedure (Epley Maneuver):
   • First-line treatment with 80-96% success rate after 1-3 treatments 2
   • Success rate of 90.7% after initial maneuver, increasing to 96% after second attempt 2
   • No postprocedural restrictions needed 1

For Lateral (Horizontal) Canal BPPV (~5-15% of cases):

1. Gufoni Maneuver: 93% success rate for geotropic type BPPV 2
2. Barbecue Roll Maneuver (Lempert): 75-90% effectiveness 2

Alternative Options:

• Observation with follow-up: May be offered as initial management 1
• Vestibular rehabilitation: Can be offered as complementary treatment 1, 2
• Self-administered exercises:
  • Self-Epley: 64% improvement rate
  • Self-Semont: 58% resolution rate
  • Brandt-Daroff exercises: 23% improvement rate (less effective than repositioning maneuvers) 2

Important Cautions

• Avoid vestibular suppressant medications: Do not routinely treat BPPV with antihistamines or benzodiazepines 1, 2

  • These medications may interfere with central compensation
  • Should be limited to short-term use (<1 week) if used at all 2
  • May cause side effects without therapeutic benefit 4

• Follow-up assessment: Reassess patients within 1 month to document resolution or persistence of symptoms 1, 2

• Patient education: Inform patients about:

  • Safety concerns and fall prevention
  • Potential for recurrence (approximately 36%)
  • Importance of follow-up 2

When to Consider Alternative Diagnoses

• Failure to respond to appropriate repositioning maneuvers
• Presence of additional neurological symptoms
• Nystagmus patterns inconsistent with BPPV
• Persistent symptoms beyond expected timeframe
• Evaluate for central nervous system disorders if symptoms persist 1, 2

By following this structured approach to positional dizziness, clinicians can efficiently diagnose and treat BPPV, which represents the most common cause of positional vertigo, while avoiding unnecessary testing and ineffective treatments.