What are the key steps in managing vertigo and what are the most effective treatments to avoid missing crucial interventions?

Vertigo: Critical "Do Not Miss" Diagnoses and Evidence-Based Management

The most critical step in managing vertigo is distinguishing life-threatening central causes (particularly posterior circulation stroke) from benign peripheral causes, followed by accurate diagnosis using the Dix-Hallpike maneuver for BPPV and treating with canalith repositioning procedures rather than medications.

Critical "Do Not Miss" Diagnoses

Central Causes Requiring Immediate Recognition

Brainstem and cerebellar stroke are the most dangerous causes of vertigo and can present identically to benign peripheral vestibular disorders in 10% of cases. 1

Key red flags suggesting central pathology include: 1

• Downbeating nystagmus on Dix-Hallpike without torsional component
• Direction-changing nystagmus without head position changes (periodic alternating nystagmus)
• Direction-switching nystagmus (beats right with right gaze, left with left gaze)
• Baseline nystagmus without provocative maneuvers
• Associated posterior circulation signs: dysarthria, dysmetria, dysphagia, sensory/motor loss, or Horner's syndrome 1

Failure to respond to conservative management (canalith repositioning or vestibular rehabilitation) should raise immediate concern for central pathology. 1

Other Important Differential Diagnoses

Vestibular migraine accounts for 14% of vertigo cases and has specific diagnostic criteria: 1

• ≥5 episodes lasting 5 minutes to 72 hours
• Current or history of migraine per International Headache Society criteria
• ≥1 migraine symptom during ≥50% of dizzy episodes (migrainous headache, photophobia, phonophobia, visual aura)
• Other causes ruled out

Diagnostic Approach

Step 1: Perform the Dix-Hallpike Maneuver

Clinicians must diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver. 1 This involves bringing the patient from upright to supine with head turned 45° to one side and neck extended 20° with the affected ear down. 1 Repeat with the opposite ear if initially negative. 1

Step 2: If Dix-Hallpike is Negative

If the patient has a history compatible with BPPV but the Dix-Hallpike exhibits horizontal or no nystagmus, perform a supine roll test to assess for lateral semicircular canal BPPV. 1, 2

Step 3: Assess Modifying Factors

Evaluate for factors that modify management: 1

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Increased risk for falling

Management Algorithm

For Confirmed BPPV (Most Common Cause)

Treat posterior canal BPPV with a particle repositioning maneuver (PRM), which achieves up to 4.1 times greater symptom resolution compared to controls. 1 Success rates reach approximately 80% with only 1-3 treatments. 2

Do NOT recommend postprocedural postural restrictions after canalith repositioning—this is a strong recommendation against this practice. 1

Do NOT routinely treat BPPV with vestibular suppressant medications such as antihistamines (meclizine) or benzodiazepines. 1 These medications:

• Have no evidence supporting efficacy as definitive primary treatment 1
• Interfere with central compensation in peripheral vestibular conditions 1
• Should only be used short-term for severe nausea/vomiting 1

Alternative Management Options

Vestibular rehabilitation (self-administered or clinician-directed) may be offered as initial treatment or for persistent symptoms. 1

Observation with assured follow-up is an option for management, though patients should be informed of typically longer symptom duration and potentially higher recurrence rates compared to PRM. 1

Testing Recommendations

What NOT to Order

Do NOT obtain radiographic imaging in patients meeting diagnostic criteria for BPPV unless additional signs/symptoms inconsistent with BPPV are present. 1

Do NOT order vestibular testing in patients meeting diagnostic criteria for BPPV unless additional vestibular signs/symptoms inconsistent with BPPV warrant testing. 1

Follow-Up and Treatment Failure

Reassess patients within 1 month after initial observation or treatment to document resolution or persistence of symptoms. 1

Evaluate patients with persistent symptoms for: 1

• Unresolved BPPV
• Underlying peripheral vestibular disorders
• Central nervous system disorders

Patient Education

Educate patients regarding: 1

• Impact of BPPV on safety (particularly fall risk)
• Potential for disease recurrence
• Importance of follow-up

Common Pitfalls to Avoid

The most dangerous pitfall is missing posterior circulation stroke, which can mimic benign peripheral vertigo in 10% of cerebellar strokes. 1 Always assess for central signs and maintain high suspicion when nystagmus patterns are atypical. 1

Do not prescribe meclizine or benzodiazepines as primary BPPV treatment—while FDA-approved for vertigo 3, guidelines strongly recommend against routine use in BPPV as they provide no definitive benefit and may impair vestibular compensation. 1

Do not assume all positional vertigo is BPPV—superior canal dehiscence syndrome presents with pressure-induced (not position-induced) vertigo and requires different diagnostic approaches. 2