What are the diagnosis and treatment options for vertigo?

Vertigo Diagnosis and Treatment

Diagnostic Approach

Vertigo diagnosis begins with determining the timing and triggers of symptoms to classify the presentation into one of three vestibular syndromes: triggered episodic (positional), spontaneous episodic, or acute vestibular syndrome. 1

Initial Classification by Timing and Triggers

• Triggered episodic vestibular syndrome (positional vertigo): Brief episodes (<1 minute) provoked by specific head or body position changes—this pattern suggests BPPV 1
• Spontaneous episodic vestibular syndrome: Episodes lasting minutes to hours without positional triggers—consider vestibular migraine, Ménière's disease, or transient ischemic attack 1
• Acute vestibular syndrome: Continuous vertigo lasting days to weeks with nausea, vomiting, and head motion intolerance—suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 1

Diagnostic Testing for BPPV (Triggered Episodic)

For patients with positional vertigo, perform the Dix-Hallpike maneuver by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20°, then repeat on the opposite side if initially negative. 1

• Posterior canal BPPV is confirmed when torsional upbeating nystagmus occurs with the Dix-Hallpike maneuver 1
• For suspected lateral canal BPPV, perform supine roll testing to identify direction-changing horizontal nystagmus 1
• Do not obtain CT or MRI for typical BPPV presentations 2

Red Flags Suggesting Central (CNS) Causes

Failure to respond to canalith repositioning procedures or vestibular rehabilitation after 2-3 attempts should raise concern for central pathology rather than BPPV. 1, 3

Critical nystagmus patterns indicating central vertigo include:

• Downbeating nystagmus on Dix-Hallpike (especially without torsional component) 1, 3
• Direction-changing nystagmus without head position changes 1, 3
• Gaze-evoked nystagmus (beats right with right gaze, left with left gaze) 1, 3
• Baseline nystagmus without provocative maneuvers 1, 3

Associated neurologic findings suggesting stroke:

• Dysarthria, dysmetria, dysphagia, sensory/motor deficits, or Horner's syndrome 1
• Severe gait instability disproportionate to vertigo 2
• Note that 10% of cerebellar strokes present similarly to peripheral vestibular disorders 1, 3

Neuroimaging Indications

• Obtain MRI of brain and posterior fossa for patients with atypical features, treatment failure after 2-3 repositioning attempts, or concerning neurologic findings 1
• CT is not useful for evaluating vertigo and should not be obtained 2
• For acute vestibular syndrome with vascular risk factors, MRI is indicated if HINTS examination suggests central pathology 2

Treatment

BPPV Treatment

Treat posterior canal BPPV with particle repositioning maneuvers (Epley or Semont maneuver), which achieve 90-98% success rates with repeated sessions. 1, 2

• Single-session failure rates range from 15-50%, so reassessment and repeat maneuvers are often necessary 1
• Do not use observation alone as initial management, as repositioning maneuvers are significantly more effective 1
• Vestibular rehabilitation can be offered as an alternative or adjunct 1

Vestibular Neuritis Treatment

• Consider short-term corticosteroids for vestibular neuritis 2
• Avoid benzodiazepines for routine treatment as they impede central vestibular compensation 4
• Vestibular rehabilitation exercises should follow initial stabilization 5, 6

Pharmacologic Symptom Management

Meclizine 25-100 mg daily in divided doses is FDA-approved for treating vertigo associated with vestibular system diseases. 7

• Use with caution in patients with asthma, glaucoma, or prostatic enlargement due to anticholinergic effects 7
• May cause drowsiness; warn patients about operating machinery 7
• For acute symptoms with severe nausea: consider metoclopramide 10 mg IM or levo-sulpiride 50 mg IV 8

Condition-Specific Management

Vestibular migraine (3.2% lifetime prevalence, 14% of vertigo cases):

• Diagnosed by ≥5 episodes lasting 5 minutes to 72 hours with migraine history and associated migraine features (headache, photophobia, phonophobia, aura) in ≥50% of episodes 1
• Treat with dietary modifications, tricyclic antidepressants, beta blockers, or calcium channel blockers 5

Ménière's disease:

• Characterized by episodic vertigo with fluctuating hearing loss, aural fullness, and tinnitus 1
• Treat with low-salt diet and diuretics 5

Follow-Up and Reassessment

Reassess all vertigo patients within 1 month after initial treatment to document resolution or persistence of symptoms. 1, 4

• Treatment failures require repeat Dix-Hallpike testing to confirm persistent BPPV versus alternative diagnosis 1
• Approximately 3% of BPPV treatment failures have underlying CNS disorders 1, 3
• Persistent symptoms after appropriate treatment warrant thorough neurologic examination and consideration of MRI 1

Risk Assessment

Assess patients for fall risk factors including impaired mobility, balance disorders, CNS disease, lack of home support, and advanced age. 1

• Older adults with dizziness have 12-fold increased fall risk 1
• One-third of community-dwelling adults >65 years fall annually, with costs exceeding $20 billion in the US 1