What treatment is appropriate for a patient with suspected vertigo, including physical therapy (PT) and medications (meds)?

Treatment of Suspected Vertigo

For a patient with suspected vertigo, perform the Dix-Hallpike maneuver to diagnose BPPV, then treat with the canalith repositioning procedure (Epley maneuver) as first-line therapy—do NOT routinely prescribe vestibular suppressant medications. 1, 2

Diagnostic Approach

Before initiating treatment, you must first confirm true vertigo (a sensation of spinning or rotation) versus vague dizziness, lightheadedness, or presyncope, which are not vertigo and require different management 1, 3. Ask specifically about:

• Onset and duration: Seconds (BPPV), minutes to hours (Ménière's), hours to days (vestibular neuritis) 1, 4
• Triggers: Positional changes suggest BPPV; spontaneous episodes suggest Ménière's or vestibular neuritis 1, 5
• Associated symptoms: Hearing loss, tinnitus, or aural fullness suggest Ménière's disease; these are absent in BPPV 1, 6
• Neurologic symptoms: Diplopia, dysarthria, ataxia, or focal weakness indicate central causes requiring urgent imaging 4, 7

Perform the Dix-Hallpike maneuver by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus that confirms posterior canal BPPV 1, 2. If negative but BPPV still suspected, perform the supine roll test for lateral canal BPPV 1, 8.

First-Line Treatment: Physical Therapy (Canalith Repositioning)

The canalith repositioning procedure (Epley maneuver) is the treatment of choice for posterior canal BPPV, with 90-98% success rates 2, 3. The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends this over medications 1, 8.

The Epley maneuver sequence involves:

1. Patient seated with head turned 45° toward affected ear 2
2. Rapidly move to supine with head hanging 20° below horizontal 2
3. Turn head 90° to unaffected side 2
4. Turn head and body another 90° (face down) 2
5. Return to sitting 2

For lateral canal BPPV, use the Gufoni maneuver or barbecue roll maneuver, with 86-100% success rates 2, 3.

Do NOT recommend postprocedural postural restrictions after repositioning procedures—they are unnecessary and not supported by evidence 1, 2, 8.

Medication Recommendations

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends AGAINST routinely treating BPPV with vestibular suppressant medications such as antihistamines (meclizine) and benzodiazepines 1, 3, 8. This is a critical point where guidelines directly contradict common practice.

Why medications should be avoided:

• They do not address the underlying mechanical problem of displaced otoconia 3, 8
• They interfere with the brain's natural vestibular compensation mechanisms, potentially prolonging symptoms 8
• They increase fall risk, especially in elderly patients 8
• Side effects include drowsiness, cognitive deficits, and impaired balance 3, 8

Meclizine may only be considered for short-term management (days, not weeks) of severe nausea or vomiting associated with acute vertigo attacks, not as primary BPPV treatment 2, 3, 9. The FDA label indicates meclizine is approved for "vertigo associated with diseases affecting the vestibular system," but this refers to conditions like Ménière's disease during acute attacks, not BPPV 9.

Vestibular Rehabilitation

Vestibular rehabilitation exercises may be offered as an adjunctive option, either self-administered or clinician-guided 1, 3. However, Brandt-Daroff exercises are significantly less effective than canalith repositioning (25% vs 80.5% resolution at 7 days) 2. Use vestibular rehabilitation primarily for:

• Patients with persistent imbalance after successful repositioning 5
• Those with vestibular neuritis or other causes of vestibular hypofunction 10, 5
• Patients who decline or cannot tolerate repositioning procedures 1

Follow-Up and Treatment Failures

Reassess all patients within 1 month after initial treatment to document resolution or persistence of symptoms 1, 3, 8. This is a strong recommendation that prevents patients from being lost to follow-up with persistent symptoms.

If symptoms persist after initial repositioning:

• Repeat the Dix-Hallpike maneuver to confirm resolution or identify persistent BPPV 2, 8
• Evaluate for canal conversion (occurs in ~6% of cases), where debris moves to a different canal requiring different repositioning 2
• Consider alternative diagnoses: vestibular migraine, Ménière's disease, vestibular neuritis, or central causes 1, 3, 8
• Refer for vestibular testing or imaging only if additional symptoms suggest central pathology or alternative diagnoses 1, 8

Common Pitfalls to Avoid

• Prescribing meclizine or other vestibular suppressants as primary treatment is the most common error—these delay recovery and have significant side effects 2, 3, 8
• Failing to perform diagnostic maneuvers and treating empirically leads to missed diagnoses and treatment failures 1, 4
• Not reassessing patients after initial treatment allows persistent symptoms to go unaddressed 2, 3
• Ordering unnecessary MRI or vestibular testing in patients who meet clear BPPV criteria wastes resources 1, 8
• Missing central causes by not asking about neurologic symptoms or examining for central nystagmus patterns 4, 7