What treatment is recommended for intermittent tinnitus, dizziness, and aural fullness, especially when triggered by head movements or standing up?

Evaluation and Management of Positional Tinnitus with Dizziness and Aural Fullness

Your symptoms—tinnitus triggered by head turning, dizziness, and aural fullness upon standing—require immediate evaluation for benign paroxysmal positional vertigo (BPPV) as the primary diagnosis, with Ménière's disease and vestibular migraine as important differential considerations. 1

Initial Diagnostic Approach

Perform the Dix-Hallpike Maneuver

• The Dix-Hallpike test is the gold standard for diagnosing posterior canal BPPV, which accounts for 42% of vertigo cases and is characterized by brief episodes triggered by head position changes 1, 2
• Bring the patient from upright to supine with head turned 45° to one side and neck extended 20°, observing for torsional upbeating nystagmus 1
• If negative on the first side, repeat with the opposite ear down before concluding the test is negative 1
• Your symptom of tinnitus "barely noticeable unless turning head" strongly suggests positional triggers consistent with BPPV 1

Rule Out Ménière's Disease

• Ménière's disease requires 2+ episodes of vertigo lasting 20 minutes to 12 hours (definite) or up to 24 hours (probable), with fluctuating hearing loss, tinnitus, or aural fullness 1
• Your "full feeling in ears upon standing" fits the aural fullness criterion, but the positional nature and brief duration suggest BPPV over Ménière's 1
• Obtain audiometry to document any low-to-mid frequency sensorineural hearing loss, which would support Ménière's diagnosis 1

Assess for Vestibular Migraine

• Vestibular migraine can present with vertigo lasting minutes to hours, often with photophobia and motion intolerance but less prominent hearing loss 1
• Inquire about migraine history, visual auras, and whether symptoms are triggered by light sensitivity rather than purely positional changes 1
• In vestibular migraine, "hearing loss" is typically bilateral and represents difficulty processing sound rather than true hearing loss 1

Treatment Algorithm

If BPPV is Confirmed (Positive Dix-Hallpike)

Perform canalith repositioning procedure (Epley maneuver) as first-line treatment immediately 1, 2:

1. Patient upright with head turned 45° toward affected ear
2. Rapidly lay back to supine head-hanging 20° position for 20-30 seconds
3. Turn head 90° toward unaffected side, hold 20 seconds
4. Turn head further 90° (nearly facedown position), hold 20-30 seconds
5. Bring patient to upright sitting position 1

For nausea management during the procedure:

• Give prochlorperazine 5-10 mg orally or IV prophylactically before repositioning if the patient previously experienced severe nausea 2
• Maximum three doses per 24 hours 2
• Do not use vestibular suppressants like meclizine routinely, as they interfere with central compensation and increase fall risk 2, 3

If Ménière's Disease is Suspected

Initiate conservative management first 1:

• Betahistine is recommended as first-choice medical treatment, though recent high-quality evidence (BEMED trial) showed no significant difference from placebo 1
• Consider dietary sodium restriction and diuretics, though evidence is limited 1
• For severe vertigo attacks with nausea: prochlorperazine, trimethobenzamide, or other antiemetics for acute symptom control 1

Oral prednisone (0.35 mg/kg daily for 18 weeks) may reduce refractory vertigo frequency by 50% and duration by 30% 4, though this requires careful monitoring for metabolic complications

If Vestibular Migraine is Diagnosed

• Address migraine prophylaxis and triggers 1
• Avoid vestibular suppressants that delay compensation 2

Critical Follow-Up

Reassess within 1 month to document resolution or persistence of symptoms 1, 2:

• If BPPV symptoms persist after repositioning, repeat the Dix-Hallpike and consider alternative diagnoses 1
• If Ménière's symptoms progress (increasing vertigo frequency, worsening hearing loss), escalate to intratympanic gentamicin or endolymphatic sac surgery 1, 5
• Document changes in vertigo, tinnitus, hearing loss, and quality of life at each visit 1

Common Pitfalls to Avoid

• Never obtain imaging (CT/MRI) unless tinnitus is unilateral, pulsatile, or associated with focal neurological abnormalities or asymmetric hearing loss 1
• Do not prescribe meclizine or other vestibular suppressants for BPPV, as they do not address the underlying pathophysiology and cause cognitive impairment and falls, especially in elderly patients 2, 3
• Do not diagnose Ménière's based on aural fullness alone—you need documented vertigo episodes of specific duration and audiometric confirmation of hearing loss 1
• Avoid missing cervicogenic causes: if vertigo is provoked by neck movements rather than head position changes, consider cervical spine evaluation 6, 7