What is the initial treatment approach for a patient experiencing vertigo?

Initial Treatment Approach for Vertigo

The initial treatment for vertigo should be a canalith repositioning procedure (CRP) for patients diagnosed with benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo. 1

Diagnosis and Classification

Before initiating treatment, it's essential to determine the type of vertigo:

• Perform the Dix-Hallpike maneuver to diagnose posterior semicircular canal BPPV (presence of torsional, upbeating nystagmus confirms diagnosis) 1
• If Dix-Hallpike is negative or shows horizontal nystagmus, perform a supine roll test to assess for lateral semicircular canal BPPV 1
• Differentiate between peripheral vertigo (BPPV, vestibular neuronitis, Ménière's disease) and central vertigo (cerebrovascular disease, multiple sclerosis) 1, 2

Treatment Algorithm

For BPPV (Positional Vertigo)

1. First-line treatment: Canalith Repositioning Procedure (CRP)

   • For posterior canal BPPV: Epley maneuver or Semont maneuver 1
   • For lateral canal BPPV: Modified Lempert roll or Gufoni maneuver 1, 3
   • Success rates reach 90-98% when repositioning maneuvers are performed correctly 1

2. Follow-up within one month to assess treatment response 1

3. If symptoms persist:

   • Repeat the CRP as the preferred treatment 1
   • Consider vestibular rehabilitation exercises 1
   • Evaluate for other semicircular canal involvement or central causes 1

For Acute Vestibular Syndrome (Spontaneous Vertigo)

1. Supportive care:

   • Position patient on their healthy side with head and trunk raised 20 degrees 3
   • Ensure a quiet but not darkened room 3

2. Pharmacological treatment:

   • Meclizine 25-100 mg daily in divided doses for symptomatic relief 4
   • Avoid routine use of vestibular suppressant medications (antihistamines, benzodiazepines) for BPPV 1

Important Considerations

• Do not routinely order imaging studies (CT or MRI) in patients who meet diagnostic criteria for BPPV unless there are additional signs/symptoms inconsistent with BPPV 1

• Do not routinely order vestibular testing in patients who meet diagnostic criteria for BPPV unless there are additional vestibular signs/symptoms inconsistent with BPPV 1

• Warning signs that may indicate central pathology requiring further investigation:

  • Abnormal neurological examination 1
  • Nystagmus that does not lessen with visual fixation 5
  • Treatment failure after 2-3 attempted repositioning maneuvers 1
  • Associated auditory or neurological symptoms 1

Pitfalls to Avoid

• Don't rely solely on medication for BPPV - repositioning maneuvers are more effective and address the underlying cause 1

• Don't miss central causes of vertigo that can masquerade as BPPV (occurs in approximately 3% of treatment failures) 1

• Don't forget to reassess treatment failures - persistent symptoms require reevaluation for unresolved BPPV or underlying disorders 1

• Don't recommend postprocedural restrictions after canalith repositioning procedures for posterior canal BPPV 1