What is the initial approach to managing vestibular nystagmus?

Initial Management of Vestibular Nystagmus

The initial approach to managing vestibular nystagmus should focus on determining whether the cause is peripheral or central, with MRI brain imaging indicated for patients with abnormal HINTS examination or neurological deficits, followed by appropriate treatment based on the underlying etiology. 1

Diagnostic Evaluation

Clinical Assessment

• Determine timing and triggers of vestibular symptoms:
  • Brief episodes (seconds) with positional changes suggest BPPV
  • Sudden severe vertigo lasting days suggests vestibular neuritis
  • Vertigo with hearing loss suggests labyrinthitis or Ménière's disease
  • Vertigo with neurological symptoms suggests stroke/central cause 1

Key Physical Examination Components

1. HINTS examination (more sensitive than early MRI for stroke detection):

   • Head Impulse test
   • Nystagmus evaluation
   • Test of Skew
   • Plus hearing assessment 2

2. Dix-Hallpike maneuver for suspected BPPV 1

3. Orthostatic vital signs to rule out orthostatic hypotension 1

Imaging Considerations

• MRI brain (without contrast) is indicated for:

  • Acute vestibular syndrome with abnormal HINTS examination
  • Patients with neurological deficits
  • High vascular risk patients with acute vestibular syndrome
  • Chronic undiagnosed dizziness not responding to treatment 1

• Avoid unnecessary imaging in clear peripheral vertigo cases 1

Treatment Approach

For Peripheral Vestibular Nystagmus

1. Benign Paroxysmal Positional Vertigo (BPPV):

   • Canalith Repositioning Procedure (Epley maneuver) - 80% success rate 1
   • Avoid routine vestibular suppressants for BPPV 1

2. Vestibular Neuritis:

   • Early corticosteroid therapy to improve recovery of peripheral vestibular function 3
   • Vestibular rehabilitation 1

3. Ménière's Disease:

   • Long-term high-dose betahistine treatment 3

4. Symptomatic Relief:

   • Meclizine: 25 mg to 100 mg daily in divided doses for vertigo associated with vestibular system diseases 4
   • Caution: May cause drowsiness; use care when driving or operating machinery 4
   • Potential anticholinergic effects: use with caution in patients with asthma, glaucoma, or prostate enlargement 4

For Central Vestibular Nystagmus

1. Pharmacological options for specific types:

   • Downbeat and upbeat nystagmus: Aminopyridines 3
   • Periodic alternating nystagmus: Baclofen 3, 5
   • Pendular nystagmus: Gabapentin and memantine 3, 5

2. Vestibular rehabilitation for persistent symptoms 1

Follow-Up Considerations

• Reassess patients who don't respond to initial treatment
• Consider central causes if symptoms persist despite appropriate therapy for peripheral disorders 6
• Head-shaking nystagmus may change over time and should not be used alone for follow-up 7

Common Pitfalls to Avoid

1. Focusing on quality of dizziness rather than timing and triggers 1
2. Failing to perform Dix-Hallpike maneuver in patients with positional vertigo 1
3. Missing central causes by not performing the HINTS examination 1
4. Routinely prescribing vestibular suppressants for BPPV 1
5. Dismissing apogeotropic positional nystagmus as BPPV when refractory to repeated canalith repositioning maneuvers (may indicate cerebellar tumor) 6

Remember that while acute vestibular syndrome is typically benign, stroke should be considered in every person with acute vestibular syndrome as it can act as a harbinger of stroke or impending cerebellar herniation 2.