What is the step-by-step management of vertigo?

Step-by-Step Management of Vertigo

Step 1: Determine if This is BPPV or Another Cause

The first critical step is to perform the Dix-Hallpike test for posterior canal BPPV (85-95% of cases) and the supine roll test for horizontal canal BPPV (10-15% of cases), as these bedside maneuvers will guide all subsequent management. 1, 2

• Posterior canal BPPV: Dix-Hallpike test provokes vertigo with torsional, upbeating nystagmus 2
• Horizontal canal BPPV: Supine roll test shows either geotropic (more common) or apogeotropic nystagmus patterns 2
• If both tests are negative but vertigo persists with positional changes, consider vestibular migraine, Ménière's disease, or vestibular neuritis 1, 3

Red flags requiring immediate imaging: downbeating nystagmus without torsional component, direction-changing nystagmus without head position changes, baseline nystagmus without provocative maneuvers, or atypical Dix-Hallpike results 1

Step 2: Treat BPPV with Canalith Repositioning Procedures (NOT Medications)

For posterior canal BPPV, perform the Epley maneuver immediately—this achieves 80-93% success after 1-3 treatments and is vastly superior to any medication (78.6-93.3% vs 30.8% for vestibular suppressants). 1, 2

Epley Maneuver Technique:

• Patient sits upright with head turned 45° toward affected ear 2
• Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds 2
• Turn head 90° to opposite side, hold 20-30 seconds 2
• Roll patient onto side with nose pointing down 45°, hold 20-30 seconds 2
• Return to sitting position 2

For Horizontal Canal BPPV:

• Geotropic variant: Barbecue Roll (Lempert) maneuver with 50-100% success rate, or Gufoni maneuver with 93% success 2
• Apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side first) 2

Critical instruction: Patients can resume normal activities immediately—postprocedural restrictions provide no benefit and may cause unnecessary complications. 1, 2

Step 3: Avoid Vestibular Suppressants for BPPV

Do NOT prescribe meclizine, antihistamines, or benzodiazepines for BPPV treatment—they are ineffective as definitive therapy and interfere with the brain's natural compensation mechanisms. 1, 2

• Vestibular suppressants may only be considered for severe nausea/vomiting during the maneuver itself, used for maximum 3-5 days 1
• These medications cause drowsiness, cognitive deficits, increased fall risk (especially in elderly), and decreased diagnostic sensitivity 1, 2
• Contraindicated in patients with asthma, glaucoma, or prostate enlargement 1

Step 4: Reassess Within 1 Month for Treatment Failures

If symptoms persist after initial treatment, repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV—repeat repositioning maneuvers achieve 90-98% success rates. 4, 1, 5

Systematic Reassessment Protocol:

• Confirm persistent BPPV: Repeat Dix-Hallpike or supine roll test 4, 5
• Check for canal conversion: Occurs in approximately 6% of cases—posterior canal may convert to lateral canal or vice versa 4, 2
• Evaluate for multiple canal involvement: Rarely, 2 semicircular canals may be simultaneously involved 4
• Consider wrong canal was treated initially: Reassess for involvement of other semicircular canals 4
• Rule out CNS disorders masquerading as BPPV: Central pathology can rarely mimic BPPV, especially with atypical features 4, 1

Step 5: Teach Self-Treatment for Motivated Patients

Self-administered Epley maneuver can be taught after at least one properly performed in-office treatment, with 64% improvement compared to only 23% for Brandt-Daroff exercises. 1, 2

• Brandt-Daroff exercises are less effective than repositioning maneuvers (24% vs 71-74% success at 1 week) but may be used for patients with physical limitations preventing standard maneuvers 2
• Patients with cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, morbid obesity, or spinal issues may require modified approaches 2

Step 6: Add Vestibular Rehabilitation Therapy as Adjunct (Not Substitute)

Vestibular rehabilitation should be offered as adjunctive therapy for patients with residual dizziness, postural instability, or heightened fall risk after successful repositioning—NOT as a substitute for canalith repositioning. 1, 2

• VRT includes habituation exercises, adaptation exercises for gaze stabilization, and compensation for vestibular deficits 2
• Patients treated with CRP plus VRT show significantly improved gait stability compared to CRP alone 2
• Home-based therapy is equally effective as clinician-supervised therapy 5

Step 7: Manage Non-BPPV Causes Differently

For Ménière's Disease:

• First-line: Dietary sodium restriction (1500-2300 mg daily) combined with diuretics 1
• Acute attacks: Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) for acute vertigo only 1
• Limit alcohol and caffeine intake 1
• Consider betahistine to increase inner ear vasodilation 1

For Vestibular Neuritis:

• Vestibular suppressants for acute symptom relief (short-term only) 3, 6
• Vestibular rehabilitation exercises after acute phase 3, 6

For Vestibular Migraine:

• Dietary modifications, tricyclic antidepressants, beta blockers, or calcium channel blockers 3
• Preventive medications when symptoms occur ≥2 days per month: beta blockers, topiramate, or candesartan as first-line 5
• Assess efficacy after 2-3 months before declaring treatment failure 5

Step 8: Assess Fall Risk in All Patients

Before any treatment, assess for modifying factors: impaired mobility/balance, CNS disorders, lack of home support, and increased fall risk—elderly patients with BPPV have particularly high fall rates. 1, 2

• Studies show 9% of patients referred to geriatric clinics have undiagnosed BPPV, with three-quarters having fallen within the previous 3 months 2
• Elderly patients warrant particular attention for depression and impaired daily activities 2

Common Pitfalls to Avoid

• Not performing repositioning maneuvers quickly enough reduces effectiveness 2
• Prescribing vestibular suppressants as primary BPPV treatment is ineffective and harmful 1, 2
• Failing to reassess after initial treatment leads to persistent symptoms that could be resolved with repeat maneuvers 4, 5
• Ordering imaging for typical BPPV is unnecessary unless diagnosis is uncertain or additional symptoms suggest central pathology 1, 5
• Abandoning treatment prematurely for non-BPPV causes—efficacy of preventive medications takes weeks to months to establish 5