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

Initial Approach to Treating Vertigo

The initial approach to vertigo depends critically on distinguishing between peripheral and central causes through focused history and physical examination, with brief episodic vertigo triggered by head movements (BPPV) treated with particle repositioning maneuvers, while acute persistent vertigo requires urgent evaluation to exclude posterior circulation stroke.

Clinical Classification by Timing and Triggers

The modern approach categorizes vertigo into three clinical syndromes that guide both diagnosis and treatment 1:

• Triggered episodic vestibular syndrome (t-EVS): Brief episodes provoked by specific head movements, most commonly benign paroxysmal positional vertigo (BPPV) 2
• Acute vestibular syndrome (AVS): Persistent vertigo lasting hours to days with nausea, gait instability, and nystagmus 2
• Spontaneous episodic vestibular syndrome: Recurrent episodes without specific triggers, including Ménière's disease and vestibular migraine 3

Initial Assessment: History and Physical Examination

Key Historical Features to Elicit

• Timing: Determine if vertigo is brief (seconds to minutes) or persistent (hours to days) 4
• Triggers: Ask specifically about provocation by lying down, rolling over in bed, bending down, or tilting the head back—these suggest BPPV 2
• Associated symptoms: Hearing loss, tinnitus, aural fullness (Ménière's disease); headache with photophobia/phonophobia (vestibular migraine); neurological symptoms (central causes) 2, 4

Critical Physical Examination Maneuvers

For triggered episodic vertigo:

• Dix-Hallpike maneuver: Positive test with upbeat-torsional nystagmus confirms posterior canal BPPV 2
• Red flags for central pathology: Downbeat nystagmus without torsional component, direction-changing nystagmus, or basal nystagmus without provocation 3

For acute persistent vertigo:

• HINTS examination (Head Impulse, Nystagmus, Test of Skew): When performed by trained practitioners, this bedside test distinguishes peripheral from central causes 2
• Neurological examination: Evaluate for focal deficits, gait abnormalities, dysarthria, or autonomic dysfunction 3

Treatment Approach by Clinical Syndrome

Brief Episodic Vertigo (BPPV)

Imaging is unnecessary for typical BPPV with positive Dix-Hallpike testing 2.

Primary treatment:

• Particle repositioning maneuvers (PRM) such as the Epley maneuver are the treatment of choice, achieving 90-98% success rates with repeated maneuvers 2
• Vestibular rehabilitation is an alternative option 2
• Reassessment at 1 month is recommended to identify treatment failures 2

Treatment failures require reevaluation:

• Repeat Dix-Hallpike testing to confirm persistent BPPV 2
• If still positive, repeat PRMs 2
• After 2-3 failed repositioning attempts, evaluate for central pathology with MRI brain and posterior fossa, as approximately 3% may have underlying CNS disorders 2, 3

Acute Persistent Vertigo

Critical distinction: peripheral vs. central causes

The prevalence of cerebrovascular disease in patients presenting with acute vestibular syndrome is approximately 25%, and may reach 75% in high vascular risk cohorts 2. Importantly, 11% of patients with acute persistent vertigo and no focal neurologic deficits were found to have acute infarct on imaging 2.

For peripheral causes (vestibular neuritis/labyrinthitis) with normal neurologic exam and reassuring HINTS:

• Initial stabilization with vestibular suppressants 5
• Meclizine 25-100 mg daily in divided doses is FDA-approved for vertigo associated with vestibular system diseases 6
• Early vestibular rehabilitation exercises after acute phase 5
• Imaging is not routinely required if examination is clearly peripheral 2

For suspected central causes or atypical features:

• MRI brain without and with IV contrast, including posterior fossa evaluation, is the preferred imaging modality 2
• CT has very low detection rate (<1%) for CNS pathology in patients with normal neurologic examination 2
• Urgent neurological consultation for stroke management 3

Spontaneous Episodic Vertigo

Ménière's disease:

• Low-salt diet combined with diuretics 5
• Consider transtympanic corticosteroid or gentamicin injections for refractory cases 1

Vestibular migraine (prevalence 3.2%, represents up to 14% of vertigo cases) 3:

• Prophylactic migraine treatment with tricyclic antidepressants, beta blockers, or calcium channel blockers 5
• Dietary modifications 5

Common Pitfalls to Avoid

• Do not assume all brief episodic vertigo is benign: Atypical nystagmus patterns (downbeat, direction-changing, or absent nystagmus on Dix-Hallpike) require imaging to exclude central pathology 2, 3
• Do not rely solely on presence/absence of focal neurologic deficits: 75-80% of patients with AVS due to posterior circulation infarct may lack focal neurologic signs 2
• Do not order CT as initial imaging for suspected central vertigo: MRI with contrast has superior sensitivity (11% detection rate vs. 6% for CT) for acute brain lesions in central positional vertigo 2
• Do not continue vestibular suppressants long-term: These medications are for acute symptom relief only and can delay central compensation 5

Medication Considerations

Meclizine precautions 6:

• Causes drowsiness—warn patients against driving or operating machinery
• Use with caution in asthma, glaucoma, or prostatic enlargement due to anticholinergic effects
• Avoid concurrent alcohol and CNS depressants
• Monitor for drug interactions with CYP2D6 inhibitors