What is the best course of treatment for worsening vertigo and dizziness?

Treatment of Worsening Vertigo and Dizziness

For worsening vertigo and dizziness, immediately perform the Dix-Hallpike test to diagnose or rule out benign paroxysmal positional vertigo (BPPV), and if positive, treat with canalith repositioning procedures (Epley maneuver) rather than medications, as this achieves 90-98% success rates. 1

Initial Diagnostic Approach

Determine the specific type of vertigo through targeted examination:

• Perform the Dix-Hallpike maneuver to identify posterior canal BPPV, looking for characteristic torsional nystagmus triggered by specific head positions (lying down, rolling over, bending down, tilting head back) 1
• Perform the supine roll test to identify lateral canal BPPV if the Dix-Hallpike is negative but positional symptoms persist 1
• Assess timing and triggers: Brief episodic vertigo triggered by head movements suggests BPPV, while acute persistent vertigo with nausea/vomiting suggests vestibular neuritis or more serious central causes 1
• Check for auditory symptoms: Unilateral hearing loss, tinnitus, or ear fullness suggests Ménière's disease rather than BPPV 1

First-Line Treatment: Canalith Repositioning Procedures

BPPV requires mechanical treatment, not medications:

• Perform the Epley maneuver (canalith repositioning procedure) for posterior canal BPPV as the primary treatment, with 80% success after 1-3 treatments 1
• Repeat repositioning maneuvers if symptoms persist after initial treatment, as success rates reach 90-98% with additional sessions 1
• Use the Gufoni maneuver or barbecue roll for lateral canal BPPV, with success rates of 86-100% 2
• Do NOT rely on meclizine or other vestibular suppressants as primary treatment for BPPV, as they do not address the underlying cause and can delay recovery by interfering with central compensation 3, 2

Management of Treatment Failures

If symptoms worsen or persist after initial repositioning maneuvers:

• Repeat the Dix-Hallpike test to confirm persistent BPPV versus other causes 1
• Perform additional repositioning maneuvers (2-4 sessions) before considering other diagnoses, as most treatment failures respond to repeated attempts 1
• Evaluate for canal conversion where debris moves from one semicircular canal to another, requiring different repositioning techniques 1
• Consider vestibular rehabilitation therapy to promote central compensation for persistent symptoms after successful repositioning 3, 2

Red Flags Requiring Neuroimaging

Obtain MRI brain (with and without contrast) if any of the following are present:

• Negative or atypical Dix-Hallpike testing despite positional symptoms, as 11% of these patients have acute central lesions 1
• Persistent symptoms after 2-3 repositioning attempts, as approximately 3% of treatment failures have CNS disorders masquerading as BPPV 3
• Associated neurological symptoms such as diplopia, weakness, numbness, dysarthria, or limb ataxia suggesting central causes 1
• Severe headache, focal neurologic deficits, or risk factors for stroke in patients with acute persistent vertigo, as 25-75% of these cases may be posterior circulation infarcts 1

Important caveat: Imaging is unnecessary for typical BPPV with characteristic nystagmus on Dix-Hallpike testing 1

Limited Role of Medications

Medications have minimal benefit for most causes of vertigo:

• Meclizine is FDA-approved only for vertigo associated with vestibular system diseases 4, but should be used short-term only for severe nausea/vomiting, not as primary treatment 2
• Avoid long-term vestibular suppressants (meclizine, benzodiazepines) as they interfere with central compensation and increase fall risk, especially in elderly patients 3, 2
• For Ménière's disease specifically, use salt restriction, diuretics, and short-term vestibular suppressants only during acute attacks 1, 2

Follow-Up and Documentation

Reassess within 1 month after initial treatment:

• Document complete resolution, improvement, or worsening of vertigo, associated symptoms (tinnitus, hearing loss), and quality of life 1, 3, 2
• If symptoms persist, reevaluate for unresolved BPPV, coexisting vestibular conditions, or serious CNS disorders requiring different treatment 1, 3
• Educate patients about recurrence risk of 15% per year, up to 50% at 5 years for BPPV 3

Common Pitfalls to Avoid

• Overreliance on meclizine when mechanical repositioning is the definitive treatment for BPPV 3, 2
• Continuing vestibular suppressants long-term, which delays recovery 3
• Ordering CT head for typical BPPV, as it has extremely low yield (<1%) and exposes patients to unnecessary radiation 1
• Failing to distinguish BPPV from central causes that can mimic peripheral vertigo but require urgent treatment 1