How to diagnose and manage a case of vertigo?

Approach to Vertigo: Diagnosis and Management

Begin by confirming true vertigo through specific questioning about spinning or rotational sensations, then perform the Dix-Hallpike maneuver to diagnose BPPV—the most common cause—and treat immediately with repositioning maneuvers if positive. 1, 2

Step 1: Confirm True Vertigo

• Ask patients to describe their sensation specifically to distinguish true vertigo (false sensation of self-motion or spinning of visual surroundings) from vague "dizziness," lightheadedness, or presyncope 2
• True vertigo never causes loss of consciousness—if syncope occurred, pursue a different diagnosis 2
• Vertigo is defined as an "illusory sensation of motion of either the self or the surroundings" 1

Step 2: Classify by Timing Pattern

Triggered Episodic (Positional):

• Brief episodes (seconds to minutes) provoked by specific head position changes suggest BPPV 1, 2
• Most common symptoms are distinct triggered spells of spinning with nausea and severe disorientation 1

Spontaneous Episodic:

• Attacks lasting minutes to hours without positional triggers suggest Ménière's disease or vestibular migraine 2
• Ménière's disease presents with fluctuating hearing loss, tinnitus, and aural fullness 2

Acute Vestibular Syndrome:

• Continuous vertigo lasting hours to days suggests vestibular neuritis or stroke 2
• Vestibular neuritis causes acute severe vertigo lasting days without hearing loss 2

Step 3: Perform the Dix-Hallpike Maneuver

This is the essential diagnostic test for BPPV and should be performed immediately in patients with positional symptoms. 1

Technique:

• Bring patient from upright to supine position with head turned 45 degrees to one side and neck extended 20 degrees 1
• Watch for characteristic nystagmus and ask about vertigo symptoms 1

Diagnostic Criteria for Posterior Canal BPPV (all must be present):

• History of repeated vertigo episodes with head position changes 1
• Vertigo associated with torsional (rotatory), upbeating nystagmus provoked by Dix-Hallpike 1
• Latency period of 5-20 seconds (rarely up to 60 seconds) between maneuver completion and symptom onset 1, 2
• Provoked vertigo and nystagmus increase then resolve within 60 seconds from nystagmus onset 1

Do not repeat the Dix-Hallpike maneuver to demonstrate fatigability—this unnecessarily subjects patients to repeated vertigo and may interfere with immediate treatment 1

Step 4: Distinguish Peripheral from Central Causes

Peripheral Vertigo Characteristics:

• Horizontal nystagmus with rotatory (torsional) component 2
• Unidirectional nystagmus 2
• Suppressed by visual fixation 2
• Fatigable with repeated testing 2

Central Vertigo RED FLAGS (require urgent evaluation):

• Pure vertical nystagmus without torsional component 2, 3
• Direction-changing nystagmus without head position changes 2, 3
• Nystagmus not suppressed by visual fixation 2, 3
• Downbeating nystagmus on Dix-Hallpike strongly suggests central pathology 3
• Baseline nystagmus without provocative maneuvers 3
• Associated neurological signs: dysarthria, dysmetria, dysphagia, sensory/motor deficits, Horner's syndrome 3
• Severe postural instability with additional neurological signs 1, 3
• Headache with vertigo 3

Step 5: Immediate Management Based on Diagnosis

For BPPV (if Dix-Hallpike positive):

• Perform canalith repositioning maneuver (particle repositioning maneuver) immediately at bedside 1
• Success rate is approximately 80% with only 1-3 treatments 1
• Patients may experience brief distress during treatment and mild motion sensitivity for hours to days afterward 1
• No imaging is indicated when clinical criteria for BPPV are met—it does not improve diagnostic accuracy and adds unnecessary cost 2

For Symptomatic Relief:

• Meclizine is FDA-approved for treatment of vertigo associated with vestibular system diseases in adults 4
• Medications are used for immediate symptom relief (nausea) but do not treat the underlying BPPV 1

For Suspected Central Causes:

• Brain MRI with and without contrast is indicated when central vertigo is suspected based on red flags 2
• Vertebrobasilar insufficiency presents with isolated transient vertigo lasting less than 30 minutes and can precede stroke by weeks to months 1, 3

Step 6: When to Pursue Additional Testing

Vestibular function testing is NOT needed when:

• BPPV diagnosis is clear by clinical criteria 2
• Patient responds appropriately to repositioning maneuvers 2

Further evaluation IS indicated when:

• Diagnosis remains unclear after history and examination 2
• Patient remains symptomatic after 2-3 repositioning treatment attempts 2, 3
• Failure to respond to conservative management mandates evaluation for central pathology 1, 3

Common Differential Diagnoses by Prevalence

• BPPV: 42% of general practice vertigo cases—brief positional episodes 2
• Vestibular neuritis: 41% of cases—acute severe vertigo lasting days without hearing loss 2
• Ménière's disease: 10% of cases—episodic vertigo with fluctuating hearing loss, tinnitus, aural fullness 2
• Vestibular migraine: 3.2% of cases—attacks lasting hours with migraine history 2
• Stroke/TIA: 3% of general practice cases, but 10% of cerebellar strokes can mimic peripheral vestibular disorders 2, 3

Critical Pitfalls to Avoid

Missing cerebellar stroke:

• Always assess for neurological signs, as 10% of cerebellar strokes present similarly to peripheral vestibular disorders 2, 3
• Pure vertical nystagmus without torsion is central until proven otherwise 2, 3

Overlooking medication effects:

• Aminoglycosides and other ototoxic drugs cause vestibular toxicity 3
• Mysoline, carbamazepine, phenytoin, antihypertensives, and cardiovascular medications can produce vertigo 1, 3

Ignoring treatment failure:

• Lack of response to repositioning maneuvers after 2-3 attempts mandates evaluation for central pathology 2, 3
• Consider concurrent diagnoses, as BPPV can occur with Ménière's disease or vestibular neuritis 1

Misinterpreting concurrent conditions:

• Patients may have more than one vestibular disorder present simultaneously 1
• BPPV does not cause constant severe dizziness unaffected by position or movement 1
• BPPV does not affect hearing or cause fainting 1