What is the workup for peripheral vertigo (benign paroxysmal positional vertigo)?

From the Guidelines

The workup for peripheral vertigo, specifically benign paroxysmal positional vertigo (BPPV), should begin with the Dix-Hallpike maneuver to diagnose posterior semicircular canal BPPV, as recommended by the strongest and most recent evidence 1. The diagnosis of BPPV can be made based on a thorough history and physical examination, focusing on the timing, triggers, and associated symptoms.

• Key diagnostic tests include:
  • The Dix-Hallpike maneuver for posterior semicircular canal BPPV, which is a strong recommendation 1.
  • The supine roll test to assess for lateral semicircular canal BPPV if the Dix-Hallpike test is negative, as recommended 1.
• The clinician should not obtain radiographic imaging or order vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging or testing, as recommended against by the evidence 1. The differential diagnosis should include other causes of imbalance, dizziness, and vertigo, and the clinician should assess patients with BPPV for factors that modify management, such as impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling, as recommended 1.
• Treatment options include:
  • Canalith repositioning procedure for posterior canal BPPV, which is a strong recommendation 1.
  • Observation with follow-up as initial management for patients with BPPV, which is an option 1.
  • Vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV, which is an option 1.
• The clinician should not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines, as recommended against by the evidence 1.

From the Research

Diagnosis of Peripheral Vertigo (Benign Paroxysmal Positional Vertigo)

• The diagnosis of benign paroxysmal positional vertigo (BPPV) can be made using the Dix-Hallpike test, which is the standard for BPPV diagnosis 2, 3, 4, 5.
• The Dix-Hallpike test is a bedside test that can be performed in the emergency department (ED) setting 2, 5.
• The test involves moving the patient's head and body in a specific way to trigger vertigo and nystagmus (abnormal eye movements) 3, 4.
• If the Dix-Hallpike test is negative, it may be repeated to increase the diagnostic yield 4.
• The HINTS (head-impulse, nystagmus, test of skew) examination can also be used to help distinguish peripheral from central etiologies of vertigo 3.

Treatment of Benign Paroxysmal Positional Vertigo

• The treatment of BPPV typically involves a canalith repositioning procedure, such as the Epley maneuver 2, 3, 5, 6.
• The Epley maneuver is a series of specific head and body movements that help to move the calcium particles (canaliths) out of the affected semicircular canal and into a part of the ear where they will not cause symptoms 5, 6.
• The treatment is usually effective and can be performed in the ED setting, reducing the need for further testing and treatment 2, 5.
• Vestibular suppressant medications, such as meclizine, are not recommended for the treatment of BPPV, as they have little therapeutic effect and can have side effects 5.