What is the initial approach to treating vertigo?

Initial Approach to Treating Vertigo

The initial approach to vertigo requires first classifying the presentation by timing and triggers to distinguish between peripheral causes (which are treated with canalith repositioning procedures or vestibular suppressants) and central causes (which require urgent imaging), rather than empirically treating all vertigo as benign paroxysmal positional vertigo (BPPV).

Step 1: Classify by Timing and Triggers

The first critical step is determining which vestibular syndrome the patient has based on symptom duration and triggers 1:

• Triggered episodic vertigo (<1 minute): Brief episodes provoked by specific head position changes suggest BPPV, superior canal dehiscence, or perilymphatic fistula 1
• Spontaneous episodic vertigo (minutes to hours): Unprovoked episodes lasting 20 minutes to hours suggest Ménière's disease, vestibular migraine, or vertebrobasilar insufficiency 1
• Acute vestibular syndrome (days): Continuous severe vertigo lasting days suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 1
• Chronic vertigo (weeks to months): Persistent symptoms suggest anxiety disorder, medication effects, or posterior fossa mass 1

Step 2: Identify Red Flags for Central Causes

Before proceeding with treatment, you must exclude central causes that require urgent imaging 2, 1:

Central warning signs include:

• Positive Romberg test (indicates central rather than peripheral pathology) 2
• Severe postural instability 1
• Cranial nerve deficits 1
• Age >50 with vascular risk factors 1
• Nystagmus that changes direction without head position changes 2
• Downward nystagmus in Dix-Hallpike maneuver 2
• Vertical skew deviation 2
• Normal head impulse test (absence of corrective saccade) 2

Critical pitfall: Up to 75-80% of posterior circulation strokes causing vertigo may lack focal neurologic deficits initially, so do not assume a normal neurologic examination excludes stroke 1.

Step 3: Perform Appropriate Physical Examination

For Triggered Episodic Vertigo (Suspected BPPV):

Only if Romberg test is negative (positive Romberg requires imaging first) 2:

• Dix-Hallpike maneuver: Bring patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus indicating posterior canal BPPV (most common type) 3
• Supine roll test: If Dix-Hallpike is negative but history compatible with BPPV, perform supine roll test to assess for lateral canal BPPV (10-15% of cases) 3, 1

For Acute Vestibular Syndrome:

• HINTS examination (Head Impulse, Nystagmus, Test of Skew): Has 92.9% sensitivity and 83.4% specificity for central causes when performed by trained clinicians 1

Step 4: Treatment Based on Diagnosis

For Posterior Canal BPPV (Most Common):

Canalith repositioning procedure (CRP) is the primary treatment 3:

• Cure rates of 86-100% with up to 4 treatments 3
• Do not recommend postprocedural postural restrictions after CRP 3
• Observation with follow-up is an acceptable alternative for initial management 3

For Lateral Canal BPPV:

• CRP appropriate for lateral canal BPPV, with higher spontaneous resolution rate than posterior canal 3
• Apogeotropic variant may be more refractory to therapy 3

For Acute Vestibular Neuritis/Labyrinthitis:

• Initial stabilizing measures with vestibular suppressant medication 4
• Followed by vestibular rehabilitation exercises 4

For Ménière's Disease:

• Low-salt diet combined with diuretics 4

Step 5: What NOT to Do

Do not routinely prescribe vestibular suppressant medications (antihistamines, benzodiazepines like meclizine or diazepam) for BPPV 3. While meclizine is FDA-approved for "vertigo associated with diseases affecting the vestibular system" 5, the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine medical therapy for BPPV 3.

Do not obtain imaging or vestibular testing in patients who meet diagnostic criteria for BPPV without additional signs/symptoms inconsistent with BPPV 3.

Do not perform Dix-Hallpike when Romberg is positive - this indicates central pathology requiring imaging first 2.

Do not treat empirically as BPPV without first excluding central causes, as CNS disorders masquerade as BPPV in 3% of treatment failures 3, 2.

Step 6: Reassessment and Follow-Up

Reassess patients within 1 month after initial observation or treatment to document resolution or persistence of symptoms 3:

• If symptoms persist, repeat appropriate positional testing 3
• Consider canal conversion (posterior to lateral or vice versa occurs in ~6% of cases) 3
• Evaluate for coexisting vestibular system dysfunction, especially in patients with history of head trauma, vestibular neuritis, Ménière's disease, or migraine 3
• Consider CNS disorders if treatment fails 3

Educate patients regarding impact on safety, fall risk, potential for recurrence, and importance of follow-up 3.