What is the best course of treatment for a patient with worsening vertigo and dizziness, referred by Ear, Nose, and Throat (ENT) specialist?

Management of Worsening Vertigo and Dizziness After ENT Referral

The first priority is to determine whether this represents a peripheral vestibular disorder (most common) or a dangerous central cause requiring urgent neuroimaging, using focused history and the HINTS examination if acute persistent vertigo is present. 1

Critical Initial Assessment: Rule Out Central Causes

Immediately evaluate for "red flags" that indicate potentially life-threatening central pathology:

• Acute persistent vertigo with abnormal neurologic examination (focal weakness, numbness, diplopia, dysarthria, ataxia) suggests posterior circulation stroke and requires urgent MRI with contrast 1
• New severe headache, facial numbness, or loss of consciousness warrants immediate imaging to exclude stroke, tumor, or hemorrhage 1
• Atypical nystagmus (direction-changing, purely vertical, or that does not suppress with visual fixation) indicates central pathology 2, 3
• Note that 25-75% of posterior circulation strokes presenting as acute vertigo may lack focal neurologic signs initially, making clinical vigilance essential 1

Diagnostic Algorithm Based on Temporal Pattern

Brief Episodic Vertigo (Seconds to Minutes, Triggered by Head Movement)

Perform the Dix-Hallpike maneuver and supine roll test immediately 4, 5:

• Positive test with typical nystagmus = BPPV diagnosis confirmed - no imaging needed 1, 4
• Negative or atypical Dix-Hallpike with persistent symptoms requires MRI head and internal auditory canal with contrast, as 6-11% will have central pathology mimicking BPPV 1
• Elderly patients, post-traumatic onset, or failure to respond to repositioning maneuvers also warrant MRI evaluation 1

Acute Persistent Vertigo (Hours to Days, Continuous)

Distinguish peripheral from central causes using the HINTS examination (Head Impulse, Nystagmus, Test of Skew) 1:

• Normal neurologic exam with peripheral HINTS findings suggests vestibular neuritis/labyrinthitis - imaging generally not required 1
• Any abnormal neurologic findings or central HINTS features mandate urgent MRI with contrast, as up to 11% have acute infarction 1
• Associated hearing loss or tinnitus strongly favors peripheral etiology 1, 2

Recurrent Episodic Vertigo (Minutes to Hours, Spontaneous)

Evaluate for Ménière's disease or vestibular migraine 1, 5:

• Ménière's disease triad: episodic vertigo (20 minutes to 12 hours) + fluctuating low-frequency hearing loss + tinnitus/aural fullness 1
• Vestibular migraine: vertigo episodes with migraine features (photophobia, phonophobia, visual aura), often bilateral auditory complaints 1, 5
• Obtain audiometry to document hearing loss pattern and guide treatment decisions 1

Treatment Algorithm

For BPPV (Most Common Cause)

Perform the Canalith Repositioning Procedure (Epley maneuver) immediately as first-line treatment 4, 5:

• Success rate 90-98% when performed correctly for posterior canal BPPV 4, 5
• For lateral canal BPPV, use Gufoni or barbecue roll maneuver (86-100% success rate) 4, 5
• Do NOT prescribe vestibular suppressants as primary treatment - they do not address the underlying cause and increase fall risk, especially in elderly patients 4, 5
• Meclizine may be used short-term only for severe nausea/vomiting, not as primary therapy 5, 6
• Reassess within 1 month to confirm resolution; persistent symptoms require reevaluation for canal conversion or other vestibular/CNS disorders 4, 5

For Ménière's Disease

Implement dietary sodium restriction and diuretics as initial management 5:

• Short-term vestibular suppressants only during acute attacks 5
• Document baseline vertigo frequency, hearing levels, tinnitus, and quality of life to guide treatment escalation 1
• Frequent follow-up in early disease allows for timely treatment adjustments if vertigo remains uncontrolled or hearing loss progresses 1
• Consider vestibular rehabilitation, intratympanic therapy, or surgical options for refractory cases 5, 7

For Vestibular Neuritis/Labyrinthitis

Initiate early vestibular rehabilitation to promote central compensation 8, 3:

• Encourage return to normal physical activity as rapidly as tolerated 8
• Repeated head, eye, and body movements help recalibrate vestibular-visual-proprioceptive relationships 8
• Short-term steroids may be considered for vestibular neuritis 7, 3
• Avoid prolonged vestibular suppressants as they interfere with central compensation 4

Critical Pitfalls to Avoid

Do not rely on CT imaging for acute vertigo evaluation - CT misses the majority of posterior circulation strokes and has very low yield (<1%) in patients with normal neurologic exams 1:

• MRI with diffusion-weighted imaging is the gold standard for detecting acute ischemia in the posterior fossa 1
• However, even MRI can miss small brainstem/cerebellar infarcts in the first 24-48 hours 1

Do not prescribe vestibular suppressants as primary or prolonged therapy 4, 5:

• They mask symptoms without treating the cause 4, 5
• They increase fall risk, particularly in elderly patients 4
• They delay central compensation in vestibular disorders 4

Do not assume peripheral cause without proper examination 1:

• One-third to two-thirds of posterior circulation strokes lack focal neurologic signs 1
• Always perform HINTS examination in acute persistent vertigo 1

Follow-Up Strategy

Establish baseline symptom severity and quality of life measures at initial visit 1:

• Document vertigo frequency, hearing levels, tinnitus severity, and functional impact 1
• Reassess within 1 month after initial treatment to determine response 4, 5
• More frequent follow-up for severe or progressive disease; less frequent for stable patients 1
• Counsel all patients on fall prevention strategies due to increased fall risk with vertigo 4