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. The test is positive when it reproduces vertigo with characteristic nystagmus (upbeating and torsional) 1.

Identify red flags for central vertigo 4:

• Nystagmus that changes direction without head position changes 4
• Downward nystagmus in Dix-Hallpike maneuver, especially without torsional component 4
• Basal nystagmus present without provocative maneuvers 4
• Associated neurologic deficits (gait disturbance, speech changes, autonomic dysfunction) 1

In acute persistent vertigo with normal neurologic exam, the HINTS examination (Head Impulse, Nystagmus, Test of Skew) can distinguish peripheral from central causes when performed by trained practitioners 1.

Initial Treatment by Etiology

BPPV (Most Common Cause)

Particle repositioning maneuvers (PRM), specifically the Epley maneuver, are the treatment of choice for confirmed BPPV, with success rates of 90-98% when repeated if necessary 1.

• Imaging is not indicated for typical BPPV with characteristic nystagmus on Dix-Hallpike testing 1
• Vestibular rehabilitation is an alternative if PRMs fail or are not tolerated 1
• Reassess at 1 month if symptoms persist 1

Acute Vestibular Neuritis/Labyrinthitis

For acute persistent vertigo with normal neurologic examination consistent with peripheral etiology 1:

• Vestibular suppressants (meclizine 25-100 mg daily in divided doses) for initial symptom control 5
• Limit vestibular suppressants to 2-3 days maximum to avoid delaying central compensation 3
• Initiate vestibular rehabilitation exercises early for faster recovery 3, 6

Important caveat: Up to 25% of patients presenting with acute vestibular syndrome may have posterior circulation stroke, and this can reach 75% in high vascular risk patients 1. Even without focal neurologic deficits, 11% may have acute infarct 1.

Ménière's Disease

When episodic vertigo occurs with unilateral hearing loss, tinnitus, or aural fullness 1, 3:

• Low-salt diet (1.5-2 g sodium daily) plus diuretics as first-line treatment 3
• Vestibular suppressants only during acute attacks 3

Central Vertigo

Any suspicion of central etiology requires urgent evaluation 4:

• MRI brain with and without contrast (especially posterior fossa) is the imaging modality of choice 1
• CT has very low yield (<1%) in patients with normal neurologic examination 1
• Treatment directed at underlying cause (stroke, vestibular migraine, demyelinating disease) 4

Management of Treatment Failures

Patients who fail initial treatment require systematic reevaluation 1:

• Repeat Dix-Hallpike testing to confirm persistent BPPV 1
• Consider involvement of other semicircular canals 1
• Approximately 3% of BPPV treatment failures have underlying CNS disorders 4

Patients unresponsive after 2-3 repositioning maneuvers should undergo neurologic examination and brain MRI to exclude central pathology masquerading as BPPV 1, 4.

Key Pitfalls to Avoid

• Do not routinely image typical BPPV with characteristic Dix-Hallpike findings 1
• Do not use prolonged vestibular suppressants beyond acute symptom control, as this delays vestibular compensation 3
• Do not dismiss acute persistent vertigo without neurologic deficits as automatically benign—posterior circulation stroke can present identically to peripheral causes in 10% of cerebellar strokes 4
• Do not rely on CT for acute persistent vertigo evaluation—MRI is far superior for detecting posterior fossa pathology 1