What is the best treatment approach for a 32-year-old female experiencing daily episodic vertigo, worsened by screen time, with a negative Dix-Hallpike test?

Management of Daily Episodic Vertigo Worsened by Screen Time with Negative Dix-Hallpike

This patient does not have BPPV and should be evaluated for alternative vestibular disorders, with vestibular rehabilitation therapy as the primary treatment approach rather than canalith repositioning procedures.

Why This Is Not BPPV

• A negative Dix-Hallpike test effectively rules out posterior canal BPPV, which accounts for 85-95% of BPPV cases 1, 2
• If BPPV is still suspected despite negative Dix-Hallpike, the supine roll test should be performed to assess for lateral (horizontal) semicircular canal BPPV, which accounts for 10-15% of cases 2
• However, the clinical presentation of daily episodic vertigo worsened by screen time is atypical for BPPV, which classically presents with brief episodes triggered by specific head position changes, not sustained visual tasks 1

Alternative Diagnosis to Consider

Vestibular migraine or persistent postural-perceptual dizziness (PPPD) should be strongly considered given:

• Daily episodic pattern rather than brief positional episodes
• Provocation by screen time (visual motion sensitivity)
• Negative positional testing

Recommended Treatment Approach

First-Line: Vestibular Rehabilitation Therapy (VRT)

VRT should be offered as the primary treatment for this patient, with the following goals 3:

• Enhance gaze stability during visual tasks
• Enhance postural stability
• Improve vertigo symptoms
• Improve activities of daily living

Key VRT Exercises for This Patient

• Head-eye movement exercises with various body postures and activities to improve gaze stability during screen use 3
• Balance exercises with reduced support base and various head/trunk orientations 3
• Gradual exposure to visual stimuli and screen time to promote habituation 3
• Repetition of movements that provoke vertigo to facilitate central compensation 3

VRT Works Through Multiple Mechanisms

• Vestibular adaptation and substitution by other eye-movement systems 3
• Substitution by vision and somatosensory cues 3
• Habituation to provocative stimuli 3
• Central neuroplastic mechanisms to achieve adaptive compensation 4

What NOT to Do

Avoid Vestibular Suppressant Medications

Do not prescribe meclizine, antihistamines, or benzodiazepines for the following reasons 2, 5:

• No evidence of effectiveness as primary treatment for non-BPPV vestibular disorders in this context
• Cause drowsiness and cognitive deficits 2
• Increase fall risk, especially in elderly patients 2
• Interfere with central compensation mechanisms that are essential for recovery 6
• May reduce the effectiveness of vestibular rehabilitation 3

Do Not Perform Canalith Repositioning Procedures

• The Epley maneuver and other repositioning procedures are only effective for confirmed BPPV with positive Dix-Hallpike or supine roll tests 1
• Performing these maneuvers without a positive diagnostic test is not indicated and will not help this patient 2, 5

Reassessment Protocol

Reassess within 1 month to evaluate treatment response 1, 5:

• If symptoms persist, consider referral to neurotology or vestibular physical therapy specialist
• Evaluate for other vestibular pathology including vestibular migraine, PPPD, or central vestibular dysfunction 4
• Consider imaging only if there are atypical features suggesting central pathology (continuous vertigo, severe headache, neurological signs) 2

Evidence Supporting VRT Over Medication

• VRT reduces both dizziness and improves balance, while vestibular suppressants only reduce dizziness without improving balance 6
• VRT is safe and effective for multiple vestibular disorders, both peripheral and central 4
• VRT works through central neuroplastic mechanisms and is effective even for central vestibular dysfunction 4

Common Pitfall to Avoid

The most critical error would be treating this as BPPV simply because the patient has vertigo. The negative Dix-Hallpike test, daily episodic pattern, and screen time provocation clearly indicate a different vestibular disorder requiring vestibular rehabilitation rather than repositioning maneuvers 2, 3, 4.