Evaluation and Treatment of Vertigo in a Casualty Setting
Immediate Diagnostic Approach: Categorize by Timing and Triggers
The most critical first step is to determine whether vertigo is triggered by head position changes (suggesting BPPV), spontaneous and acute (suggesting vestibular neuritis or stroke), or episodic and spontaneous (suggesting Ménière's disease or vestibular migraine), as this classification drives all subsequent management decisions. 1, 2
Initial Assessment Framework
Classify vertigo by timing pattern rather than relying on patient descriptions of "spinning" versus "lightheadedness," which are unreliable 1, 2
- Triggered episodic (lasts <1 minute, provoked by position changes): suggests BPPV 1
- Acute vestibular syndrome (continuous for days, with nausea/vomiting): suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 1
- Spontaneous episodic (minutes to hours, unprovoked): suggests Ménière's disease or vestibular migraine 1
Immediately assess for neurological red flags including diplopia, dysarthria, numbness, weakness, severe headache, or abnormal gait, which mandate urgent evaluation for central causes 2
Bedside Diagnostic Maneuvers
For Triggered Positional Vertigo (Suspected BPPV)
Perform the Dix-Hallpike maneuver by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20°, observing for characteristic torsional upbeating nystagmus that confirms posterior canal BPPV 1, 3
If Dix-Hallpike is negative but history suggests BPPV, perform the supine roll test to assess for lateral canal BPPV by turning the head 90° to each side while supine 1, 3
For Acute Spontaneous Vertigo (Suspected Central vs. Peripheral)
- Distinguish peripheral from central causes through examination of nystagmus pattern, gait stability, and associated neurological signs 1, 4
- Note: 75-80% of patients with posterior circulation stroke present without focal neurological deficits, so normal neurologic exam does not exclude stroke 2
Imaging Decisions
Do NOT obtain imaging for typical BPPV with positive Dix-Hallpike test and characteristic nystagmus 1, 3
Obtain MRI brain with contrast when: 1, 2, 3
- Neurological symptoms are present beyond isolated vertigo
- Atypical nystagmus patterns are observed
- Patient fails appropriate treatment for presumed peripheral vertigo
- Acute vestibular syndrome with high vascular risk factors
For episodic vertigo with hearing loss or aural fullness, either CT temporal bone without contrast or MRI head and internal auditory canal (with or without contrast) is appropriate 1
For persistent vertigo with neurological symptoms, MRI head and internal auditory canal without contrast (or with contrast) is the initial imaging of choice 1
Immediate Treatment by Diagnosis
BPPV (Most Common Cause)
Perform canalith repositioning procedures (CRP) immediately, as the Epley maneuver achieves 90-98% success rates when performed correctly and is the treatment of choice for posterior canal BPPV. 3
- For posterior canal BPPV: Epley maneuver (canalith repositioning) 3
- For lateral canal BPPV: Modified CRP techniques specific to lateral canal 1
- Avoid vestibular suppressants as they are not indicated for BPPV and may delay compensation 1
Acute Vestibular Neuritis/Labyrinthitis
Provide short-term vestibular suppressants (3-5 days maximum) to manage acute symptoms, not as long-term therapy 5, 3
Add antiemetics for neurovegetative symptoms: 7
- Metoclopramide 10 mg IM once or twice daily
- Prochlorperazine (alternative option) 8
Initiate vestibular rehabilitation early (after acute phase) to promote central compensation 5, 3, 9
Position patient on healthy side with head and trunk raised 20 degrees during acute phase 7
Ménière's Disease (If Suspected)
Diagnose when: ≥2 episodes of vertigo lasting 20 minutes to 12 hours, with fluctuating sensorineural hearing loss, tinnitus, or aural fullness 1
Obtain audiogram to document sensorineural hearing loss 1
Acute attack management: 1
Long-term management: 1
Vestibular Migraine
Consider when: ≥5 episodes of moderate-to-severe vestibular symptoms lasting 5 minutes to 72 hours with migraine features in ≥50% of episodes 2
Prophylactic treatment: calcium channel antagonists, tricyclic antidepressants, or beta-blockers 8, 10
Critical Management Pitfalls to Avoid
Do NOT prescribe prolonged vestibular suppressants beyond 3-5 days, as they impair central compensation and vestibular rehabilitation 5, 3, 9
Do NOT rely on patient descriptions of symptom quality ("spinning" vs "lightheadedness") for diagnosis; focus on timing and triggers instead 1, 2
Do NOT assume normal neurologic exam excludes stroke in acute vestibular syndrome, especially with vascular risk factors 2
Warn patients about drowsiness with meclizine and caution against driving or operating machinery; avoid concurrent alcohol use 6
Use meclizine with caution in patients with asthma, glaucoma, or prostatic enlargement due to anticholinergic effects 6
Mandatory Follow-Up
Reassess within 1 month after initial treatment to document resolution or persistence of symptoms 1, 5, 3
If symptoms persist, evaluate for: 1, 3
- Unresolved BPPV (repeat positioning maneuvers)
- Incorrect initial diagnosis
- Canal conversion (posterior to lateral or vice versa)
- Underlying peripheral vestibular dysfunction
- Central nervous system disorders (3% of treatment failures) 1
- Potential for BPPV recurrence
- Increased fall risk, especially in elderly
- Importance of follow-up for persistent symptoms
- Safety considerations (driving restrictions per local guidelines) 9