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 treatment directed at the specific underlying etiology rather than empiric symptom management alone.

Clinical Assessment Framework

History: Timing and Triggers Over Symptom Quality

The most diagnostically useful information comes from identifying timing patterns and specific triggers rather than asking patients to describe symptom quality 1, 2:

• Brief episodic vertigo triggered by head movements (lasting seconds to minutes): Suggests benign paroxysmal positional vertigo (BPPV) 1
• Acute persistent vertigo (lasting hours to days): Consider vestibular neuritis, labyrinthitis, or posterior circulation stroke 1
• Episodic vertigo with hearing loss or aural fullness: Suggests Ménière's disease 1, 3

Critical Physical Examination Components

Perform the Dix-Hallpike maneuver to confirm BPPV when brief episodic positional vertigo is suspected 1. Key findings that distinguish peripheral from central causes 4:

• Central vertigo warning signs:

  • Nystagmus that changes direction without head position changes 4
  • Downward nystagmus in Dix-Hallpike (especially without torsional component) 4
  • Direction-changing nystagmus with gaze (right with rightward gaze, left with leftward gaze) 4
  • Basal nystagmus without provocative maneuvers 4
  • Abnormal neurologic examination findings 1

• Peripheral vertigo characteristics:

  • Typical rotatory nystagmus with Dix-Hallpike that fatigues 1
  • Normal neurologic examination 1

Treatment by Specific Diagnosis

BPPV (Most Common Cause)

Particle repositioning maneuvers (PRMs) are the treatment of choice for confirmed BPPV, with 90-98% success rates when repeated as needed 1:

• Perform Epley maneuver or other canalith repositioning procedure 1, 5
• Imaging is unnecessary for typical BPPV with characteristic nystagmus on Dix-Hallpike 1
• Reassess at 1 month if symptoms persist 1

Acute Vestibular Neuritis/Labyrinthitis

For acute persistent vertigo with normal neurologic examination consistent with peripheral cause 3, 5:

• Vestibular suppressant medication (meclizine 25-100 mg daily in divided doses) for initial symptom control 6
• Vestibular rehabilitation exercises following initial stabilization 3, 2
• Symptoms typically improve over days to weeks 3

Ménière's Disease

When episodic vertigo occurs with hearing loss and aural fullness 1, 3:

• Low-salt diet combined with diuretics as first-line treatment 3, 5
• Consider transtympanic corticosteroid or gentamicin injections for refractory cases 2

When to Suspect Central Causes

Approximately 25% of acute vestibular syndrome cases and up to 75% in high vascular risk patients have posterior circulation stroke, even without focal neurologic deficits 1. Red flags requiring urgent evaluation 1, 4:

• Persistent vertigo with atypical nystagmus patterns (see above)
• Associated neurologic symptoms (diplopia, dysarthria, ataxia, weakness)
• Failure to respond to appropriate peripheral vertigo treatment after 2-3 attempts 1, 4
• Vascular risk factors in acute persistent vertigo 1

Imaging Indications

MRI brain (with and without contrast, including posterior fossa) is indicated when 1:

• Central vertigo is suspected based on examination findings
• Atypical features present (negative or atypical Dix-Hallpike with positional symptoms)
• Treatment failure after appropriate repositioning maneuvers 1, 4
• Associated neurologic deficits 1

CT imaging has very low yield (<1%) in vertigo with normal neurologic examination and should not be routinely obtained 1.

Treatment Failure Evaluation

Reassess at 1 month for persistent symptoms 1. Treatment failures require systematic reevaluation:

• Repeat Dix-Hallpike to confirm persistent BPPV 1
• If positive, repeat repositioning maneuvers (success rate 90-98% with additional attempts) 1
• Evaluate for central causes if atypical features present: Approximately 3% of BPPV treatment failures have underlying CNS disorders 1, 4
• Consider involvement of different semicircular canals than originally diagnosed 1

Common Pitfalls

• Do not rely on symptom quality alone—timing and triggers are more diagnostically reliable 2, 5
• Do not obtain routine imaging for typical BPPV—it is clinically diagnosed and imaging adds no value 1
• Do not miss central causes masquerading as peripheral vertigo—11% of acute persistent vertigo without focal deficits may have stroke 1
• Do not use vestibular suppressants long-term—they impede vestibular compensation and rehabilitation 3, 2