What is the initial assessment and management approach for a patient presenting with vertigo?

Initial Assessment and Management of Vertigo

The initial assessment of a patient with vertigo should include the Dix-Hallpike maneuver to diagnose posterior semicircular canal BPPV, followed by a supine roll test if the Dix-Hallpike is negative, and the HINTS examination to differentiate peripheral from central causes of vertigo. 1, 2

Diagnostic Approach

Step 1: History Taking - Focus on Timing, Triggers, and Associated Symptoms

• Timing and duration: Seconds (BPPV), hours (Menière's, vestibular migraine), days (vestibular neuritis)
• Triggers: Position changes (BPPV), spontaneous (Menière's, vestibular neuritis)
• Associated symptoms: Hearing loss, tinnitus, aural fullness (Menière's), photophobia (vestibular migraine), neurological symptoms (central causes)

Step 2: Physical Examination

1. Dix-Hallpike maneuver (gold standard for posterior canal BPPV)

   • Bring patient from upright to supine position with head turned 45° to one side and neck extended 20°
   • Positive test: Torsional, upbeating nystagmus 1

2. Supine roll test (if Dix-Hallpike negative)

   • Assess for lateral semicircular canal BPPV 1

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

   • More sensitive than early MRI (100% vs 46%) for detecting stroke 2
   • Red flag: Nystagmus that does not lessen with visual fixation suggests central cause

4. Neurological examination

   • Check for other neurological deficits that may suggest central causes

Step 3: Identify Red Flags Requiring Urgent Evaluation

• Sudden severe headache
• New neurological symptoms
• Inability to walk or stand
• Persistent vomiting
• Altered mental status 2

Differential Diagnosis

Peripheral Causes (Most Common)

• Benign Paroxysmal Positional Vertigo (BPPV)

  • Brief episodes triggered by position changes
  • Positive Dix-Hallpike test

• Vestibular Neuritis

  • Sudden severe vertigo lasting days
  • Unidirectional horizontal nystagmus

• Menière's Disease

  • Episodes with hearing loss, tinnitus, aural fullness
  • Characteristic audiometric findings

Central Causes (Require Urgent Evaluation)

• Stroke/TIA

  • Sudden onset with neurological deficits
  • Abnormal HINTS exam

• Vestibular Migraine

  • Variable duration, history of migraine
  • Photophobia, mild/absent hearing loss

Management Approach

For BPPV (Most Common Cause)

1. Canalith Repositioning Procedure (e.g., Epley maneuver)

   • First-line treatment with 80% success rate
   • 1-3 treatments typically needed 1, 2
   • Postprocedural restrictions are NOT recommended 1

2. Observation with follow-up

   • May be offered as initial management 1

3. Vestibular rehabilitation

   • Self-administered or clinician-directed
   • Particularly helpful for persistent symptoms 1, 2

For Vestibular Neuritis

• Early corticosteroid therapy
• Symptomatic treatment for acute symptoms
• Vestibular rehabilitation exercises 2

Pharmacotherapy

• Avoid routine use of vestibular suppressants

  • Clinicians should NOT routinely treat BPPV with antihistamines or benzodiazepines 1

• Meclizine

  • Indicated for vertigo associated with vestibular system diseases
  • Dosage: 25-100 mg daily in divided doses
  • Caution: May cause drowsiness, avoid alcohol and operating machinery
  • Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 3

Imaging and Additional Testing

• Do NOT obtain radiographic imaging in patients meeting diagnostic criteria for BPPV without additional concerning symptoms 1
• Do NOT order vestibular testing in patients meeting diagnostic criteria for BPPV without additional vestibular symptoms 1
• Consider CT or MRI in patients with:
  • Advanced age (>65 years)
  • Vascular risk factors
  • History of falls
  • Acute onset with neurological findings 2

Follow-up and Monitoring

• Reassess within 1 month after initial treatment to document resolution or persistence of symptoms 1, 2
• Evaluate treatment failures for unresolved BPPV or underlying disorders 1
• Educate patients about potential recurrence (15% per year for BPPV) and impact on safety 2

Common Pitfalls to Avoid

• Focusing on the quality of dizziness rather than timing and triggers
• Failing to perform the Dix-Hallpike maneuver in patients with positional vertigo
• Routinely prescribing vestibular suppressants for BPPV
• Missing central causes of vertigo by not performing the HINTS examination
• Ordering unnecessary imaging studies in patients with clear peripheral vertigo