What is the appropriate workup and management for patients experiencing bouts of vertigo?

Management of Vertigo: Diagnostic Workup and Treatment Approach

The most effective approach to vertigo management begins with determining the specific cause through targeted diagnostic testing, followed by appropriate treatment based on etiology, with canalith repositioning procedures being the first-line treatment for the most common cause, benign paroxysmal positional vertigo (BPPV).

Diagnostic Workup

Initial Assessment

• Determine if vertigo is triggered by specific head movements (suggesting BPPV) or occurs spontaneously 1
• Assess timing and duration: brief episodes (seconds to minutes) suggest BPPV; longer episodes (hours to days) suggest vestibular neuritis or Ménière's disease 2
• Note associated symptoms such as hearing loss, tinnitus, neurological symptoms, or headache 1, 2

Key Diagnostic Tests

• Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV - observe for characteristic torsional, upbeating nystagmus 1
• If Dix-Hallpike is negative but history suggests BPPV, perform supine roll test to assess for lateral canal BPPV 1
• The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) helps distinguish peripheral from central causes of vertigo 2

When to Consider Imaging

• Imaging is not recommended for typical BPPV with positive Dix-Hallpike test 1
• Consider MRI brain with contrast when:
  • Vertigo presents with additional neurological symptoms
  • Atypical nystagmus patterns are observed
  • Patient fails to respond to appropriate treatment
  • Symptoms suggest central pathology 1

Treatment Approach

For BPPV (most common cause)

• Canalith repositioning procedures (CRP) are the treatment of choice for posterior canal BPPV 1
• The Epley maneuver has success rates of 90-98% when performed correctly 1
• Postprocedural restrictions are not necessary after CRP 1
• Reassess patients within 1 month after initial treatment to confirm symptom resolution 1

For Vestibular Neuritis

• Short-term vestibular suppressant medications for acute symptoms 3
• Vestibular rehabilitation exercises to promote central compensation 4
• Avoid long-term use of vestibular suppressants as they may delay recovery 4

For Ménière's Disease

• Low-salt diet and diuretics are first-line treatments 3, 2
• Lifestyle modifications including limiting caffeine, alcohol, and maintaining regular sleep patterns 4

Medication Considerations

• Vestibular suppressant medications (antihistamines, benzodiazepines) are not recommended as routine treatment for BPPV 1
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases but should be used cautiously 5
• Long-term use of vestibular suppressants can interfere with central compensation mechanisms 4, 6
• Medications increase fall risk, especially in elderly patients 4, 6

Management of Treatment Failures

• For patients who fail initial treatment, reevaluate for:

  • Persistent BPPV (may require repeated repositioning maneuvers)
  • Incorrect initial diagnosis
  • Underlying peripheral vestibular or central nervous system disorders 1

• Treatment failure rates for a single-session repositioning maneuver range from 15-50%, but success rates reach 90-98% with repeated procedures 1

Patient Education and Follow-up

• Counsel patients about potential recurrence of BPPV (5-13.5% at 6 months; 10-18% at 1 year) 1
• Educate patients about increased fall risk, especially in elderly patients 1
• Schedule follow-up within 1 month after initial treatment 1
• Advise patients to report atypical symptoms (hearing loss, gait disturbance, non-positional vertigo) that may indicate underlying disorders 1

Common Pitfalls to Avoid

• Overreliance on vestibular suppressant medications which can delay recovery 4
• Failure to perform appropriate diagnostic maneuvers (Dix-Hallpike, supine roll test) 1
• Unnecessary imaging in patients with typical BPPV 1
• Missing central causes of vertigo by not performing a thorough neurological examination 1, 2