What is the initial management for a patient presenting with vertigo symptoms?

Initial Management of Vertigo

The initial management of vertigo requires immediate classification by timing and triggers to distinguish life-threatening central causes from benign peripheral causes, followed by targeted physical examination maneuvers before considering any treatment or imaging. 1

Immediate Classification by Vestibular Syndrome

The first step is categorizing vertigo into one of four vestibular syndromes based on timing and triggers, not symptom quality: 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

Critical Initial Physical Examination

Romberg Test First

Perform the Romberg test before any other maneuvers, as a positive result indicates central pathology requiring urgent imaging rather than peripheral causes: 2

• If Romberg is positive: Do NOT perform Dix-Hallpike testing; proceed directly to urgent MRI brain without and with IV contrast 2
• If Romberg is negative: Proceed with syndrome-specific examination maneuvers 1, 2

HINTS Examination for Acute Vestibular Syndrome

For patients with acute persistent vertigo (lasting days), perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew), which has 92.9% sensitivity and 83.4% specificity for central causes: 1

Central warning signs requiring urgent imaging: 1, 2

• Nystagmus that changes direction without head position changes
• Downward nystagmus during Dix-Hallpike maneuver
• Vertical skew deviation
• Normal head impulse test (absence of corrective saccade)

Dix-Hallpike Maneuver for Triggered Episodic Vertigo

For brief positional vertigo (<1 minute), perform the Dix-Hallpike maneuver to test for posterior canal BPPV, which accounts for 85-95% of BPPV cases: 3, 1

• If negative but history compatible with BPPV, perform the Supine Roll Test to diagnose lateral canal BPPV (10-15% of BPPV cases) 1
• May need to repeat at a separate visit to avoid false-negative results 1

Urgent Imaging Indications

Order urgent MRI brain without and with IV contrast for: 1, 2

• Positive Romberg test with vertigo
• Central warning signs on HINTS examination
• Severe postural instability
• Focal neurologic deficits
• Age >50 with vascular risk factors

Critical pitfall: CT head without contrast is inadequate for detecting CNS pathology in isolated vertigo and misses posterior fossa strokes in the acute phase 1, 2. Up to 75-80% of posterior circulation strokes causing vertigo lack focal neurologic deficits initially 1.

Initial Treatment Based on Diagnosis

For BPPV (Triggered Episodic Vertigo)

Perform canalith repositioning procedures (CRP) appropriate for the affected canal: 3

• Posterior canal BPPV responds to Epley or Semont maneuvers
• Lateral canal BPPV has cure rates of 86-100% with up to 4 CRP treatments 3
• Do NOT treat empirically as BPPV without first excluding central causes 2

For Acute Vestibular Neuritis/Labyrinthitis

Symptomatic pharmacotherapy for vestibular suppressant effect: 4

• Meclizine 25-100 mg daily orally in divided doses is FDA-approved for vertigo associated with vestibular system diseases 4
• Warning: Causes drowsiness; patients must avoid driving and alcohol 4
• Use with caution in asthma, glaucoma, or prostate enlargement due to anticholinergic effects 4

Follow with vestibular rehabilitation exercises after initial stabilization 5

What NOT to Do

• Do NOT perform Dix-Hallpike when Romberg is positive, as this indicates central pathology requiring imaging first 2
• Do NOT assume normal neurologic examination excludes stroke, as most posterior circulation strokes causing vertigo lack focal deficits initially 1
• Do NOT rely on patient's description of "spinning" instead of focusing on timing and triggers 1
• Do NOT discharge without imaging when Romberg is positive with vertigo 2
• Do NOT order routine blood tests (CBC, chemistry) as standard practice, since vertigo diagnosis is fundamentally clinical 1

Reassessment for Treatment Failures

If symptoms persist after initial treatment for BPPV: 3

• Repeat the appropriate positional testing (Dix-Hallpike or supine roll test)
• Consider "canal conversion" (posterior to lateral canal or vice versa occurs in 6% of cases) 3
• Evaluate for involvement of different semicircular canals, including rare anterior canal BPPV 3
• CNS disorders masquerading as BPPV are found in 3% of treatment failures 3, 1
• Consider coexisting vestibular dysfunction, particularly in patients with head trauma, vestibular neuritis, Ménière's disease, or migraine 3