What are the treatment options and diagnostic tests for vertigo?

Vertigo Treatment and Diagnostic Tests

The most effective approach to vertigo management begins with proper classification into one of three patterns (Acute Vestibular Syndrome, Episodic Vestibular Syndrome, or Chronic Vestibular Syndrome) followed by targeted diagnostic testing and specific treatments based on the identified cause. 1

Diagnostic Tests for Vertigo

Initial Diagnostic Approach

• Classification by timing and triggers into:
  • Acute Vestibular Syndrome (AVS): Continuous vertigo lasting days
  • Episodic Vestibular Syndrome: Recurrent vertigo lasting minutes to hours
  • Chronic Vestibular Syndrome: Persistent dizziness lasting months 1

Physical Examination Tests

1. Dix-Hallpike maneuver: Gold standard for diagnosing posterior canal BPPV

   • Performed by bringing patient from upright to supine with head turned 45° to one side and neck extended 20° 2
   • Positive test shows torsional, upbeating nystagmus 2

2. Supine roll test: For lateral semicircular canal BPPV when Dix-Hallpike is negative 2

3. HINTS examination (Head-Impulse, Nystagmus, Test of Skew):

   • More sensitive than CT for posterior circulation stroke (92.9% sensitivity) 1, 3
   • Should be performed in acute vestibular syndrome 1

4. Head impulse test: Abnormal in peripheral causes (sensitivity 76.8%, specificity 89.1%) 3

Imaging Studies

• MRI brain: Preferred when central causes are suspected; higher sensitivity than CT for posterior fossa lesions 1
• CT head: Low sensitivity (~10%) for posterior fossa strokes but can exclude hemorrhage in emergency settings 1
• CT temporal bone: For assessing bony abnormalities in peripheral vertigo 1
• MRA Head and Neck: When vertebrobasilar insufficiency is suspected 1

Laboratory Testing

• Selective laboratory tests based on history:
  • Complete blood count
  • Electrolytes
  • Glucose
  • Thyroid function tests
  • Vitamin B12 levels 1

Treatment Options

BPPV Treatment

1. Canalith Repositioning Procedures:

   • Strong recommendation for posterior canal BPPV 2
   • Epley maneuver has high success rates (around 80%) with only 1-3 treatments 2
   • Postprocedural restrictions are not recommended 2

2. Observation:

   • May be offered as initial management with assured follow-up 2
   • BPPV may resolve spontaneously within weeks, but treatment reduces fall risk 2

Vestibular Rehabilitation

• Effective for persistent dizziness after BPPV resolution 1
• Can be self-administered or clinician-directed 2, 1
• Accelerates central compensation for vestibular imbalance 1

Pharmacologic Treatment

1. Vestibular Suppressants:

   • Meclizine: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 4
   • Not recommended for routine BPPV treatment 2
   • Short-term use only due to potential side effects (drowsiness, dry mouth) 1, 4
   • Caution with concurrent CNS depressants including alcohol 4
   • Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 4

2. Medication Review:

   • Deprescribing when possible for chronic dizziness in seniors 1
   • Common culprits: sedatives, antihypertensives, muscle relaxants 1

Follow-up and Monitoring

• Reassessment within 1 month after initial treatment 2, 1
• Evaluate treatment failures for persistent BPPV or underlying disorders 2
• Education about potential recurrence (15% per year for BPPV) 1

Management Algorithm by Vertigo Type

For BPPV

1. Diagnose with Dix-Hallpike or supine roll test
2. Perform appropriate canalith repositioning procedure
3. No vestibular suppressant medications
4. Reassess within 1 month

For Vestibular Neuritis

1. Short-term vestibular suppressants for symptom control
2. Early vestibular rehabilitation
3. Gradual return to normal activities

For Menière's Disease

1. Low-salt diet and diuretics
2. Short-term vestibular suppressants during acute attacks
3. Consider transtympanic treatments for refractory cases

For Central Causes (stroke, MS, etc.)

1. Urgent neuroimaging (preferably MRI)
2. Neurological consultation
3. Treatment of underlying condition

Special Considerations

• Fall prevention is critical, especially in elderly patients (12-fold increased risk) 1

• Red flags requiring urgent evaluation:

  • Sudden severe headache
  • New neurological symptoms
  • Inability to walk or stand
  • Persistent vomiting
  • Altered mental status 1

• Avoid vestibular suppressants in patients requiring vestibular compensation 2

By following this structured approach to diagnosis and treatment, most vertigo cases can be effectively managed with significant improvement in symptoms and quality of life.