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 the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) being the most effective bedside test to distinguish between these causes when performed by trained practitioners. 1, 2

Peripheral vs. Central Vertigo Assessment

Clinical Differentiation

• Peripheral vertigo characteristics:

  • Rotational vertigo with sudden onset
  • Associated hearing loss, tinnitus, or aural fullness
  • Symptoms provoked by position changes
  • Nausea and vomiting
  • Nystagmus that suppresses with visual fixation
  • Normal neurological exam 2

• Central vertigo characteristics:

  • Gradual onset vertigo
  • Persistent symptoms
  • Associated neurological symptoms
  • Nystagmus that doesn't suppress with fixation
  • Abnormal neurological exam 2

HINTS Examination

When performed by specially trained practitioners, the HINTS examination is more sensitive than early MRI for detecting stroke (100% versus 46%) 1. The examination includes:

• Head impulse test
• Nystagmus assessment
• Test of skew

Management Based on Specific Diagnosis

Benign Paroxysmal Positional Vertigo (BPPV)

• First-line treatment: Canalith Repositioning Procedures (CRPs) 2

  • Epley maneuver: 90.7% success rate after initial maneuver
  • Gufoni Maneuver: 93% success rate for geotropic type BPPV
  • Barbecue Roll Maneuver: 75-90% effectiveness for lateral canal BPPV

• Important: Vestibular suppressants should NOT be used routinely for BPPV 2

Vestibular Neuritis

• Characterized by sudden, severe vertigo lasting days with no hearing loss
• Treatment: Vestibular suppressants acutely and vestibular rehabilitation 2

Ménière's Disease

• Episodes typically last 20 minutes to 12 hours
• Treatment: Focus on preventing or reducing attack frequency and severity
• Vestibular suppressants should only be used short-term during acute episodes 2

Medication Management

When medications are indicated for symptomatic relief:

• Meclizine: 25 mg to 100 mg daily in divided doses 3

  • Caution: May cause drowsiness; patients should avoid driving and alcohol
  • Use with caution in patients with asthma, glaucoma, or prostate enlargement

• Prokinetic antiemetics (domperidone, metoclopramide) may help manage nausea without significantly interfering with vestibular compensation 2

Imaging Considerations

• Peripheral vertigo: CT temporal bone without contrast or MRI head/internal auditory canal without/with contrast may be appropriate 1, 2

• Central vertigo: MRI head/internal auditory canal without/with contrast is recommended 1, 2

• Important: Imaging evaluation in BPPV with typical nystagmus on Dix-Hallpike testing is unnecessary 1

Follow-up

Patients should be reassessed within 1 month to document resolution or persistence of symptoms 2

Special Considerations

Elderly Patients

• Require lower medication doses to avoid adverse effects
• Higher risk of falls with untreated vestibular disorders
• Vestibular rehabilitation may be particularly beneficial in reducing BPPV recurrence 2

Safety Concerns

• Educate patients about fall prevention
• Warn about potential drowsiness with medications
• Advise against driving or operating dangerous machinery while experiencing symptoms 2, 3

Remember that while most cases of vertigo are benign peripheral causes, central causes (particularly posterior circulation stroke) must be ruled out as they may require urgent treatment 4, 5.