What is the initial approach to treating a patient with vertigo?

Initial Approach to Treating Vertigo

The initial approach to treating vertigo should focus on identifying the cause, with particular emphasis on distinguishing between benign paroxysmal positional vertigo (BPPV) and other causes, followed by appropriate targeted interventions such as canalith repositioning procedures for BPPV or medication for other causes. 1, 2

Diagnostic Assessment

• Determine if vertigo is triggered by positional changes relative to gravity (lying down, rolling over, bending down, tilting head back), which suggests BPPV 1
• Perform the Dix-Hallpike test to confirm diagnosis of BPPV - a positive test shows characteristic nystagmus 1
• Evaluate for central causes if nystagmus changes direction without changes in head position, is downward without torsional component, or if basal nystagmus is present without provocative maneuvers 2
• Assess for associated symptoms such as hearing loss, aural fullness, neurological symptoms, or headache that may indicate specific causes 1, 2

Treatment Algorithm for BPPV

• For confirmed BPPV (positive Dix-Hallpike test with characteristic nystagmus), perform canalith repositioning procedures (CRP) such as the Epley maneuver as first-line treatment 1, 3
• Success rates of CRP reach 90-98% when additional repositioning maneuvers are performed for persistent cases 1
• Reassess treatment response at approximately 1 month after initial diagnosis to balance between early resolution and potential persistent symptoms 1
• For patients who fail initial treatment, repeat the Dix-Hallpike test and perform additional repositioning maneuvers if still positive 1

Treatment for Other Common Causes of Vertigo

• For vestibular neuritis/labyrinthitis: Initial stabilizing measures and vestibular suppressant medication (such as meclizine 25-100 mg daily in divided doses), followed by vestibular rehabilitation exercises 4, 5
• For Menière's disease: Low-salt diet and diuretics 5, 3
• For vestibular migraine: Dietary changes, tricyclic antidepressants, beta blockers or calcium channel blockers 5
• For anxiety-related vertigo: Consider selective serotonin reuptake inhibitors 5

Medication Considerations

• Meclizine (25-100 mg daily in divided doses) can be used for symptomatic relief of vertigo associated with vestibular system diseases 4
• Caution patients about potential drowsiness with meclizine and advise against driving or operating dangerous machinery 4
• Avoid alcohol while taking meclizine due to increased CNS depression 4
• Use meclizine with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 4

When to Consider Further Evaluation

• Patients who fail to respond to appropriate treatment, especially after 2-3 attempts at repositioning maneuvers for presumed BPPV 1, 2
• Presence of atypical or neurological symptoms such as gait disturbance, speech problems, or autonomic dysfunction 1, 2
• Approximately 3% of BPPV treatment failures may have an underlying CNS disorder 2
• Consider MRI of the brain and posterior fossa for patients with persistent symptoms or suspected central causes 1
• About 10% of cerebellar strokes may initially present similarly to peripheral vestibular disorders 2

Pitfalls and Caveats

• Imaging is generally not indicated for typical BPPV with positive Dix-Hallpike test and should be reserved for atypical presentations or treatment failures 1
• Central causes of vertigo can occasionally mimic BPPV, so careful evaluation of nystagmus characteristics and associated symptoms is essential 2
• Avoid prolonged use of vestibular suppressants as they may delay central compensation and recovery 6
• Recognize that the traditional categorization of dizziness into four types (vertigo, presyncope, disequilibrium, light-headedness) has limited clinical usefulness; focus instead on timing and triggers 3
• The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) can help distinguish peripheral from central etiologies in acute vestibular syndrome 3