What is the best course of action for severe vertigo (dizziness) lasting 4 days with vomiting that stopped 1 day ago?

Immediate Evaluation for Central Vertigo

This patient requires urgent evaluation to rule out stroke or other central causes, as persistent vertigo lasting 4 days exceeds the typical duration of benign peripheral vertigo and warrants immediate neurological assessment. 1

Critical Red Flags Assessment

First, immediately assess for neurological red flags that indicate central vertigo requiring emergency evaluation:

• Speech difficulties (dysphasia/dysarthria), difficulty swallowing (dysphagia), or visual disturbances suggest brainstem involvement or stroke 1
• Motor or sensory deficits (weakness, numbness in limbs) are key red flags requiring urgent imaging 1
• Severe imbalance disproportionate to vertigo or inability to stand/walk indicates possible central pathology 1
• Drop attacks (sudden falls without loss of consciousness) suggest central vertigo 1
• Persistent vertigo lasting more than 24 hours without improvement requires immediate attention 1

Common pitfall: Vertebrobasilar stroke may masquerade as peripheral vestibular disorders like vestibular neuritis, and up to 75-80% of stroke patients with vertigo may lack obvious focal neurologic deficits 2, 3

Differential Diagnosis Based on Duration

The 4-day duration helps narrow the differential:

• Vestibular neuritis: Severe rotational vertigo lasting 12-36 hours with decreasing disequilibrium over 4-5 days, without hearing loss, tinnitus, or aural fullness 4
• Labyrinthitis: Sudden severe vertigo with profound hearing loss and prolonged vertigo (>24 hours), not episodic or fluctuating 4
• BPPV: Brief episodes lasting seconds to less than a minute, not continuous for days 4
• Stroke/ischemia: Vertigo may last minutes with severe imbalance; insults are permanent and don't fluctuate, often with other neurologic symptoms 4

Physical Examination Priorities

Perform targeted examination to differentiate central from peripheral causes:

• HINTS examination (head-impulse, nystagmus, test of skew) is critical for distinguishing peripheral from central etiologies 5
• Direction-changing nystagmus or downbeating nystagmus without torsional component indicates central pathology 1
• Baseline nystagmus present without provocative maneuvers suggests central cause 1
• Dix-Hallpike maneuver to assess for BPPV, though unlikely given continuous 4-day duration 4, 5

Symptomatic Management

For severe nausea/vomiting that persists, short-term vestibular suppressants are appropriate only for symptom control, not as definitive treatment:

• Prochlorperazine 5-10 mg orally or IV, maximum three doses per 24 hours, for severe nausea/vomiting 2, 6
• Promethazine IM 10 mg once or twice daily is more effective for vertigo symptoms than ondansetron, though ondansetron better controls nausea 7
• Meclizine can be used as-needed (PRN) rather than scheduled to avoid interfering with vestibular compensation 6

Critical warning: Vestibular suppressants should not be used routinely or long-term, as they interfere with central vestibular compensation, increase fall risk (especially in elderly), and cause cognitive impairment 4, 2, 6

Definitive Management Algorithm

If central causes are ruled out and vestibular neuritis is diagnosed:

1. Discontinue vestibular suppressants after initial 24-48 hours of severe symptoms 6
2. Initiate vestibular rehabilitation early to promote compensation 6, 5
3. Consider corticosteroids for vestibular neuritis, though evidence for routine use requires further trials 3

If BPPV is identified (unlikely with 4-day continuous symptoms):

• Canalith repositioning procedure (Epley maneuver) is first-line treatment, not medications 4, 2

Mandatory Follow-Up

Reassess within 1 month after initial treatment to document resolution or persistence of symptoms 4, 2, 6. Persistent symptoms require re-evaluation for alternative diagnoses, including central causes 2.

Key pitfall to avoid: Do not attribute neurological symptoms to anxiety or overlook subtle neurological signs in the presence of obvious vestibular symptoms 1