What is the best initial treatment for a patient with persistent vertigo, mild earache, fatigue, and lethargy, with a negative Dix-Hallpike maneuver and normal lab results?

Treatment of Persistent Vertigo with Negative Dix-Hallpike

This patient does NOT have BPPV and should NOT receive the Epley maneuver, hydrochlorothiazide, or lorazepam—start meclizine for symptomatic relief while pursuing further diagnostic evaluation for alternative vestibular disorders.

Why This is NOT BPPV

The clinical presentation argues strongly against posterior canal BPPV:

• Negative Dix-Hallpike maneuver effectively rules out posterior canal BPPV, which accounts for 85-95% of all BPPV cases 1
• The positive head impulse test (corrective saccade) indicates peripheral vestibular hypofunction, not BPPV 1
• Persistent, continuous vertigo that "always presents" is incompatible with BPPV, which characteristically causes brief episodes (seconds to minutes) triggered only by specific positional changes 1, 2
• The bilateral earache, fatigue, lethargy, and recent viral exposure in a household contact suggest vestibular neuritis or labyrinthitis 1

Why the Epley Maneuver is Contraindicated

The Epley maneuver should only be performed when the Dix-Hallpike test is positive 3. The American Academy of Otolaryngology-Head and Neck Surgery guidelines explicitly state that canalith repositioning procedures work by moving otoconia from the posterior semicircular canal back to the vestibule—a mechanism that only applies when BPPV is confirmed 3. Performing the Epley maneuver on a patient without BPPV:

• Provides no therapeutic benefit 3, 4
• May cause unnecessary nausea, vomiting, or sense of falling 3
• Delays appropriate diagnosis and treatment 1, 2

Appropriate Initial Management

Symptomatic Treatment with Meclizine

Meclizine is FDA-approved for vertigo associated with vestibular system diseases 5 and is appropriate for this patient's likely diagnosis of vestibular neuritis/labyrinthitis. While the American Academy of Otolaryngology-Head and Neck Surgery recommends against vestibular suppressants for BPPV specifically 1, 4, this recommendation does not apply to other vestibular disorders where these medications have established efficacy 5.

Why NOT Hydrochlorothiazide or Lorazepam

• Hydrochlorothiazide has no role in acute vestibular disorders and is used for Meniere's disease prophylaxis, which this patient does not have
• Lorazepam may provide symptomatic relief but causes significant drowsiness, cognitive impairment, and fall risk 1, 4—meclizine is safer with similar efficacy 5

Diagnostic Workup

Since the Dix-Hallpike is negative but vestibular pathology is evident:

• Perform the supine roll test to evaluate for horizontal canal BPPV (10-15% of BPPV cases) 1, 4
• Consider vestibular neuritis or labyrinthitis given the positive head impulse test, viral prodrome, bilateral earache, and persistent symptoms 1
• Imaging is NOT indicated unless atypical features develop suggesting central pathology 1, 4

Follow-Up and Vestibular Rehabilitation

• Reassess within 1 month to evaluate treatment response 1, 4
• Vestibular rehabilitation therapy should be offered as primary treatment for vestibular neuritis/labyrinthitis to enhance gaze stability, postural stability, and symptom improvement 1, 4
• If symptoms persist beyond 4-6 weeks, refer to neurotology or vestibular physical therapy specialist 1

Common Pitfalls to Avoid

• Do not perform repositioning maneuvers without a positive diagnostic test 3, 2
• Do not assume all positional vertigo is BPPV—the head impulse test findings indicate a different pathology 1
• Do not withhold vestibular suppressants in non-BPPV vestibular disorders where they are indicated 5
• Repeated Dix-Hallpike testing may increase diagnostic yield if initially negative but high clinical suspicion remains 6, 7, but this patient's presentation is not consistent with BPPV