What is the workup and treatment for vertigo?

Workup and Treatment of Vertigo

The most effective approach to vertigo management requires proper classification of vertigo type through specific diagnostic tests, followed by targeted treatment based on the underlying cause, with the Dix-Hallpike test being the gold standard for diagnosing the most common cause - benign paroxysmal positional vertigo (BPPV). 1, 2

Diagnostic Approach

Initial Classification

1. Determine if vertigo is peripheral or central:
   • Peripheral causes (inner ear): BPPV, vestibular neuritis, Ménière's disease
   • Central causes (brainstem/cerebellum): stroke, TIA, multiple sclerosis, tumors

Key Diagnostic Tests

• Dix-Hallpike maneuver: Gold standard for posterior canal BPPV diagnosis 1, 2

  • Positive when vertigo with torsional, upbeating nystagmus occurs when patient moves from sitting to supine with head turned 45° and neck extended 20°
  • Test both sides if initial test is negative

• Supine roll test: For lateral (horizontal) canal BPPV 2

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

  • More sensitive than early MRI for stroke detection (100% vs 46%)
  • Critical for distinguishing peripheral from central vertigo 2
  • Central signs: nystagmus that doesn't lessen with focus, skew deviation

Imaging Recommendations

• Peripheral vertigo: Generally no imaging needed initially

  • If imaging indicated: CT temporal bone without contrast OR MRI head/IAC without/with contrast 1, 2

• Central vertigo or unclear etiology:

  • MRI head/internal auditory canal without/with contrast (preferred)
  • MRI more sensitive than CT for posterior fossa lesions 1, 2

Treatment Algorithms

For BPPV (most common cause)

1. Canalith Repositioning Procedures (80-90% success rate with 1-2 treatments) 2
   • Posterior canal: Epley maneuver
   • Lateral canal: Barbecue roll or Gufoni maneuver
   • Follow-up within 1 month to confirm resolution 1, 2

For Vestibular Neuritis/Labyrinthitis

1. Short course of steroids
2. Vestibular rehabilitation (self-administered or clinician-guided) 2

For Ménière's Disease

1. Diuretics (reduces endolymph volume and vertigo attacks by 56% compared to placebo)
2. Lifestyle modifications:
   • Abundant water intake
   • Sleeping in dark room
   • Stress management techniques 2

For Vestibular Migraine

• Prophylaxis with beta-blockers, anticonvulsants, or antidepressants 2

For Symptomatic Relief of Vertigo

• Medications:
  • Dopamine receptor antagonists (prochlorperazine, metoclopramide)
  • Benzodiazepines (lorazepam)
  • 5-HT3 antagonists (ondansetron)
  • Prokinetic antiemetics (domperidone, metoclopramide) 2

Special Considerations

Fall Risk Management

• Educate patients about increased fall risk, especially elderly
• Home safety assessment
• Regular physical activity (30 minutes cardio twice weekly) 2

Follow-up

• Reassess within 1 month after initial treatment
• Evaluate treatment failures for:
  • Persistent BPPV
  • Incorrect diagnosis
  • Underlying peripheral vestibular or CNS disorders 2

Common Pitfalls to Avoid

1. Missing central causes: Always perform HINTS exam in acute vertigo
2. Inadequate diagnosis: Don't rely solely on patient description; perform appropriate diagnostic maneuvers
3. Medication overuse: Vestibular suppressants may delay central compensation if used long-term
4. Incomplete treatment: Single repositioning maneuver may not be sufficient; follow-up is essential
5. Overlooking medication side effects: Many drugs can cause vertigo, particularly aminoglycosides, cycloserine, and certain anticonvulsants 2

By following this structured approach to vertigo evaluation and management, clinicians can effectively diagnose the underlying cause and provide appropriate treatment to reduce morbidity and improve quality of life for patients with vertigo.