What is the approach to diagnosing and treating a case of vertigo?

Approach to Vertigo: Diagnostic and Treatment Algorithm

The initial approach to vertigo must categorize patients by timing and triggers—not symptom quality—into three vestibular syndromes (Acute Vestibular Syndrome, Triggered Episodic, or Spontaneous Episodic), as this framework directly guides physical examination and distinguishes benign peripheral disorders from dangerous central causes like stroke. 1

Step 1: Classify by Timing Pattern

Triggered Episodic Vestibular Syndrome (Seconds to <1 Minute)

• Symptoms: Brief vertigo episodes triggered by specific head movements 1
• Most likely diagnosis: Benign Paroxysmal Positional Vertigo (BPPV) 2
• Key features: Distinct triggered spells of spinning, nausea, severe disorientation lasting seconds to minutes, with residual unsteadiness 2
• Critical point: BPPV does NOT cause constant dizziness unaffected by position, does NOT affect hearing, and does NOT cause fainting 2

Spontaneous Episodic Vestibular Syndrome (Minutes to Hours)

• Duration 20 minutes to 12 hours with hearing symptoms: Ménière's disease 2
  • Must have: Fluctuating low-to-mid frequency sensorineural hearing loss, tinnitus, or aural fullness 2
  • Hearing loss fluctuates but eventually involves all frequencies over time 2
• Duration 5 minutes to 72 hours with migraine features: Vestibular migraine 3
  • Requires current or history of migraine, with migraine symptoms during ≥50% of dizzy episodes 3
  • May present with photophobia, phonophobia, or visual aura 2

Acute Vestibular Syndrome (Days to Weeks)

• Symptoms: Acute persistent vertigo with constant symptoms, nausea/vomiting, gait instability, head-motion intolerance 2
• Differential: Vestibular neuritis (peripheral) vs. posterior circulation stroke (central) 1
• Critical distinction: Presence of neurologic symptoms increases stroke risk dramatically 2

Step 2: Perform Targeted Physical Examination

For Triggered Episodic Pattern (Suspected BPPV)

Dix-Hallpike Maneuver (Posterior Canal BPPV):

• Bring patient from upright to supine with head turned 45° to one side, neck extended 20°, affected ear down 2
• Positive test: Torsional, upbeating nystagmus with vertigo 2
• Repeat with opposite ear if initial maneuver negative 2

Supine Roll Test (Lateral Canal BPPV):

• Perform if Dix-Hallpike shows horizontal or no nystagmus 2
• Roll head side-to-side while patient supine 2

For Acute Vestibular Syndrome

HINTS Examination (Head Impulse, Nystagmus, Test of Skew):

• Critical: HINTS has 100% sensitivity for posterior circulation stroke when performed by trained practitioners—superior to early MRI (46% sensitivity) 1
• Red flags suggesting CENTRAL cause:
  • Downbeating nystagmus on Dix-Hallpike 3, 4
  • Direction-changing nystagmus without head position changes 3, 4
  • Gaze-evoked nystagmus that does not fatigue and is not suppressed by visual fixation 3
  • Baseline nystagmus without provocative maneuvers 3, 4

Complete Neurologic Examination:

• Assess for dysarthria, dysmetria, dysphagia, sensory/motor deficits, Horner's syndrome—all indicate posterior circulation involvement 3
• Severe postural instability with additional neurological signs distinguishes vertebrobasilar insufficiency from peripheral causes 3

Step 3: Determine Need for Imaging

NO Imaging Required:

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike 1
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner 1
• Rationale: CT head has <1% diagnostic yield for isolated dizziness 1; normal imaging/laboratory testing cannot confirm BPPV 2

MRI Brain WITHOUT Contrast Indicated:

• Abnormal neurologic examination 1
• HINTS examination suggesting central cause 1
• High vascular risk patients with acute vestibular syndrome 1
• Unilateral or pulsatile tinnitus 1
• Asymmetric hearing loss 1
• Failure to respond to conservative management (raises concern for non-BPPV diagnosis) 3, 4

Special Imaging Considerations:

• Conventional angiography: Reserved for suspected positional insufficiency of posterior circulation or vertebral artery dissection 2
• Avoid CT head: Should not replace MRI when stroke suspected 1

Step 4: Treatment Based on Diagnosis

BPPV (Posterior Canal)

Primary Treatment:

• Canalith repositioning procedure (Epley maneuver) is mandatory first-line treatment with 80-93% success rates after 1-3 treatments 4
• Perform at time of diagnosis or refer to clinician who can perform 2
• Do NOT recommend postprocedural postural restrictions after repositioning 2

Medication Approach:

• Do NOT routinely treat BPPV with vestibular suppressants (antihistamines/benzodiazepines) 2, 4
• Meclizine 25-100 mg daily may ONLY be considered for severe nausea/vomiting during the maneuver itself or in patients who refuse repositioning 4
• Maximum duration: 3-5 days 4
• Contraindications: Asthma, glaucoma, prostate enlargement 4, 5
• Warnings: Drowsiness, cognitive deficits, anticholinergic effects, increased fall risk especially in elderly 4, 5

Alternative Option:

• Observation with follow-up may be offered as initial management, as BPPV can resolve spontaneously within weeks 2
• Caution: Unsteadiness increases fall risk, especially in seniors—encourage quick professional help 2

Ménière's Disease

First-Line Preventive Therapy:

• Dietary sodium restriction: 1500-2300 mg daily 4
• Diuretics combined with salt restriction 4
• Limit alcohol and caffeine intake 4

Acute Attack Management:

• Short-term vestibular suppressants: Meclizine 25-100 mg daily in divided doses 4, 5
• Betahistine (histamine analogue) may increase inner ear vasodilation 4

Refractory Cases:

• Intratympanic dexamethasone or gentamicin 1

Vestibular Migraine

• Migraine prophylaxis and lifestyle modifications 1
• Dietary changes, tricyclic antidepressant, beta blocker or calcium channel blocker 6

Acute Vestibular Neuritis

• Initial vestibular suppressant medication for stabilization 6
• Followed by vestibular rehabilitation exercises 6

Vertebrobasilar Insufficiency/Stroke

• Activate stroke protocol immediately 1
• Urgent neurology consultation 1
• Isolated transient vertigo lasting <30 minutes without hearing loss can precede stroke by weeks to months 3

Step 5: Vestibular Rehabilitation and Follow-Up

Indications for Vestibular Rehabilitation:

• Persistent dizziness from any vestibular cause 4
• Chronic imbalance 4
• Incomplete recovery 4
• Can be self-administered or therapist-directed 2, 4

Mandatory Follow-Up:

• Reassess within 1 month after initial treatment to document resolution or persistence 4
• Counsel on fall risk, potential recurrence, and importance of follow-up 4

Fall Risk Assessment:

• Ask about falls in past year, feeling unsteady, worry about falling 1
• Perform Get Up and Go test or Tinetti Balance Assessment if positive responses 1

Critical Pitfalls to Avoid

• Never assume peripheral cause without proper examination: 10% of cerebellar strokes mimic peripheral vestibular processes 3
• Atypical Dix-Hallpike results increase risk of central pathology requiring imaging 4
• Do not use vestibular suppressants as primary BPPV treatment: Efficacy only 30.8% vs. 78.6-93.3% for repositioning maneuvers 4
• Recognize concurrent diagnoses: BPPV can occur with Menière's disease, vestibular neuritis, or post-trauma 2
• Elderly patients with long-standing Ménière's may not manifest frank vertigo but rather vague dizziness 2
• Educate patients to distinguish true vertigo (spinning) from lightheadedness (presyncope)—loss of consciousness is NEVER Ménière's disease 2