What are the next steps for a patient with chronic dizziness, whose heart issues have been ruled out and vertigo treatment has failed?

Chronic Dizziness After Failed Vertigo Treatment: Next Steps

When vertigo treatment has failed and cardiac causes are excluded, you must systematically reevaluate for three critical possibilities: persistent BPPV requiring repeat repositioning maneuvers, coexisting peripheral vestibular disorders, or central nervous system pathology masquerading as peripheral vertigo.

Immediate Reevaluation Strategy

Repeat Diagnostic Testing for Persistent BPPV

• Repeat the Dix-Hallpike test to confirm whether BPPV is still present, as 8-50% of patients have persistent BPPV after initial treatment failure 1
• If the Dix-Hallpike remains positive, perform additional canalith repositioning maneuvers (CRP), which achieve 90-98% success rates with repeated attempts 1
• For lateral canal BPPV, repeat the supine roll test and consider that the apogeotropic variant may be more refractory to treatment 1
• Examine for involvement of other semicircular canals beyond those originally diagnosed 1

Screen for Central Nervous System Disorders

Critical warning signs that mandate CNS evaluation include: 1, 2

• Nystagmus that changes direction without changes in head position 2
• Downward nystagmus in the Dix-Hallpike maneuver, especially without torsional component 2
• Basal nystagmus present without provocative maneuvers 2
• Lack of response after 2-3 attempted repositioning maneuvers 1
• Associated auditory or neurological symptoms 1

Obtain Detailed History to Identify Alternative Diagnoses

• Determine if vertigo is provoked by positional changes relative to gravity (lying down, rolling over, bending, tilting head back) versus spontaneous vertigo 1, 2
• Assess for vestibular migraine, which represents up to 14% of vertigo cases and has a 3.2% prevalence 2
• Evaluate for Meniere's disease by asking about unilateral hearing loss 3
• Establish if original symptoms persist or if you're dealing only with chronic dizziness syndrome 4

Advanced Diagnostic Workup

When to Order Neuroimaging

Obtain MRI of the brain and posterior fossa in these scenarios: 1, 2

• Atypical or refractory symptoms after 2-3 repositioning attempts 1
• Any central nystagmus patterns 2
• Associated neurological symptoms 1
• Note that approximately 3% of BPPV treatment failures have an underlying CNS disorder 1, 2
• 10% of cerebellar strokes present similarly to peripheral vestibular processes 2

Physical Examination Priorities

• Perform thorough neurological examination including gait and balance assessment 1, 2
• Conduct HINTS examination (head-impulse, nystagmus, test of skew) to distinguish peripheral from central etiologies 3
• Check for orthostatic blood pressure changes 3
• Assess for impediments to central vestibular compensation: visual problems (cataracts, squints), proprioceptive deficits (diabetic or alcoholic neuropathy), neurological or orthopedic problems 4

Treatment Algorithm Based on Findings

If Persistent BPPV Confirmed

• Repeat CRP as the treatment of choice 1
• For cases refractory to multiple CRP, surgical plugging of the involved posterior semicircular canal or singular neurectomy has >96% success rate, though data quality limits definitive recommendations 1

If Central Vertigo Identified

• Direct treatment at the underlying cause 2
• For stroke or TIA: urgent neurological management 2
• For vestibular migraine: initiate migraine prophylaxis 2

If Chronic Dizziness Syndrome Without Active Pathology

• Implement vestibular rehabilitation and counseling for all patients 4
• Discontinue or reduce vestibular suppressants and tranquilizers 4
• Address multidisciplinary factors: treat visual deficits, proprioceptive problems, psychological disorders, fear of falling 4

Common Pitfalls to Avoid

• Do not assume initial diagnosis was correct—approximately 3% have missed CNS disorders 1, 2
• Do not continue vestibular suppressants long-term, as they impede central compensation 4
• Do not order extensive testing without systematic clinical evaluation first 5, 3
• Do not miss the 1-month reassessment window, as this balances spontaneous resolution rates (20-80%) against unnecessary suffering 1