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

Initial Approach to Treating Vertigo

The initial approach to vertigo requires first distinguishing between peripheral and central causes through focused history and physical examination, with treatment directed by the specific diagnosis—most commonly benign paroxysmal positional vertigo (BPPV) treated with particle repositioning maneuvers, or acute vestibular syndrome requiring evaluation for posterior circulation stroke.

Step 1: Categorize the Clinical Presentation

The timing and triggers of vertigo guide the diagnostic approach 1:

• Brief episodic vertigo triggered by head movements: Suggests BPPV, confirmed by Dix-Hallpike maneuver 2
• Acute persistent vertigo: Defines acute vestibular syndrome (AVS), requiring differentiation between peripheral (vestibular neuronitis/labyrinthitis) and central causes (posterior circulation stroke) 2
• Spontaneous episodic vertigo: Consider vestibular migraine (prevalence 3.2%, represents up to 14% of vertigo cases) or Ménière's disease 3

Step 2: Distinguish Peripheral from Central Vertigo

Red Flags for Central Vertigo (Require Urgent Evaluation)

• Nystagmus of changing direction without head position changes 3
• Downward nystagmus in Dix-Hallpike maneuver, especially without torsional component 3
• Basal nystagmus present without provocative maneuvers 3
• Associated neurologic deficits: Gait disturbance, speech changes, autonomic dysfunction 2
• Lack of response to canalith repositioning maneuvers 3

Critical caveat: 75-80% of patients with posterior circulation stroke causing AVS may have NO focal neurologic deficits 2. In acute persistent vertigo, 11% of patients without focal neurologic signs have acute infarct on imaging 2.

Step 3: Initial Treatment Based on Diagnosis

For BPPV (Most Common Peripheral Cause)

• Perform particle repositioning maneuvers (PRMs) as first-line treatment 2
• Success rate: 90-98% with repeated maneuvers if initial treatment fails 2
• No imaging required for typical BPPV with characteristic nystagmus on Dix-Hallpike testing 2
• Reassess at 1 month if symptoms persist 2

For Acute Vestibular Syndrome with Normal Neurologic Exam

• Most common causes: Vestibular neuronitis or labyrinthitis (benign peripheral) 2
• However: 25% of AVS cases are due to cerebrovascular disease, up to 75% in high vascular risk patients 2
• Symptomatic treatment: Meclizine 25-100 mg daily in divided doses for vestibular vertigo 4
• Consider MRI brain (especially posterior fossa) if HINTS examination suggests central cause or patient has vascular risk factors 2

For Treatment Failures

Reevaluate after initial treatment failure 2:

• Repeat Dix-Hallpike testing to confirm persistent BPPV 2
• If positive, repeat PRMs (success rate 90-98%) 2
• If symptoms persist after 2-3 repositioning attempts: Obtain thorough neurologic examination and consider MRI brain/posterior fossa 2
• Important: 3% of BPPV treatment failures have underlying CNS disorders 2, 3

Step 4: Imaging Decisions

When Imaging is NOT Required

• Typical BPPV with characteristic nystagmus on Dix-Hallpike testing 2
• Peripheral vertigo with normal neurologic exam and reassuring HINTS examination 2

When Imaging IS Required

• Atypical features: Negative or atypical Dix-Hallpike testing despite positional symptoms 2
• Treatment failure: No improvement after 2-3 repositioning maneuvers 2, 3
• Central signs: Any red flags for central vertigo 3
• AVS with vascular risk factors: Even without focal neurologic deficits 2
• Preferred modality: MRI brain without and with IV contrast, focusing on posterior fossa 2

Critical Pitfalls to Avoid

• Do not assume normal neurologic exam excludes stroke: Up to 80% of posterior circulation strokes causing vertigo lack focal neurologic signs 2
• Do not obtain imaging for typical BPPV: This is unnecessary and increases costs without benefit 2
• Do not delay reassessment: Evaluate treatment response at 1 month to identify persistent BPPV or missed diagnoses 2
• Meclizine cautions: Use with caution in asthma, glaucoma, or prostate enlargement; warn patients about drowsiness and avoiding alcohol 4