What is the initial approach to treating vertigo?

Initial Approach to Treating Vertigo

The initial approach to vertigo depends critically on whether it is peripheral (inner ear) or central (brainstem/cerebellar) in origin, with peripheral causes treated primarily through canalith repositioning procedures for BPPV and vestibular suppressants avoided as routine therapy, while central causes require urgent neuroimaging and stroke protocol activation. 1, 2

Step 1: Classify by Timing and Triggers (Not Symptom Quality)

The first step is to categorize vertigo into vestibular syndromes based on timing rather than relying on patient descriptions of "spinning":

• Triggered episodic (<1 minute): Suggests BPPV, superior canal dehiscence, or perilymphatic fistula—brief episodes provoked by specific head position changes 3
• Spontaneous episodic (minutes to hours): Suggests Ménière's disease, vestibular migraine, or vertebrobasilar insufficiency—unprovoked episodes lasting 20 minutes to hours 3
• Acute vestibular syndrome (days): Suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke—continuous severe vertigo lasting days 3
• Chronic (weeks to months): Suggests anxiety disorder, medication effects, or posterior fossa mass 3

Step 2: Identify Red Flags for Central Causes

Before proceeding with peripheral vertigo treatment, you must exclude central causes that require urgent imaging:

Central warning signs include:

• Positive Romberg test (indicates central rather than peripheral pathology) 2
• Severe postural instability out of proportion to vertigo 3
• Cranial nerve deficits beyond vertigo 3
• Age >50 with vascular risk factors 3
• 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 3

Step 3: Perform Targeted Physical Examination

For Triggered Episodic Vertigo (Suspected BPPV):

• 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) 1
• Supine roll test: If Dix-Hallpike shows horizontal or no nystagmus but history compatible with BPPV, perform supine roll test to assess for lateral canal BPPV (10-15% of cases) 1, 3

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 3

Do NOT perform Dix-Hallpike when Romberg is positive, as this indicates central pathology requiring imaging first 2

Step 4: Imaging Strategy

When to Order Urgent MRI:

Order MRI brain without and with IV contrast immediately for:

• Positive Romberg test with vertigo 2
• Central warning signs on HINTS examination 3
• Severe postural instability 3
• Any focal neurologic deficits 3

MRI detects acute brain lesions in 11% of patients with acute persistent vertigo and no focal neurologic deficits 2, 3

What NOT to Do:

• Do not use CT head without contrast as definitive imaging—it misses posterior fossa strokes in the acute phase 2, 3
• Do not discharge without imaging when Romberg is positive with vertigo 2

Step 5: Treatment Based on Diagnosis

For Posterior Canal BPPV (Most Common):

Perform canalith repositioning procedure (CRP) immediately—this is a strong recommendation with cure rates of 86-100% with up to 4 treatments 1

• Do NOT recommend postprocedural postural restrictions after CRP—this is a strong recommendation against such restrictions 1
• Observation with follow-up is an option for initial management if patient prefers 1

For Lateral Canal BPPV:

Perform CRP appropriate for lateral canal BPPV, with cure rates of 86-100% with up to 4 treatments 1

Medication Approach:

Do NOT routinely treat BPPV with vestibular suppressant medications such as antihistamines (meclizine) or benzodiazepines—this is a recommendation against routine use 1

While meclizine is FDA-approved for vertigo associated with vestibular system diseases at 25-100 mg daily in divided doses 4, the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine use of vestibular suppressants for BPPV 1

Exception: Vestibular suppressants may be considered for acute vestibular neuritis/labyrinthitis as initial stabilizing measures, followed by vestibular rehabilitation 5

Vestibular Rehabilitation:

May offer vestibular rehabilitation (self-administered or with clinician) as treatment option for BPPV 1

Step 6: Reassessment and Treatment Failure

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

If Symptoms Persist:

• Repeat appropriate positional testing (Dix-Hallpike or supine roll test) 1
• Consider "canal conversion" (lateral to posterior or vice versa occurs in ~6% of cases) 1
• Consider anterior canal BPPV or simultaneous involvement of 2 canals 1
• Recognize that CNS disorders masquerade as BPPV in 3% of treatment failures 1
• Evaluate for coexisting vestibular dysfunction, especially in patients with history of head trauma, vestibular neuritis, Menière's disease, or migraine 1

Step 7: Patient Education

Educate patients regarding:

• Impact of BPPV on safety, especially fall risk 1
• Potential for disease recurrence 1
• Importance of follow-up 1

Common Pitfalls to Avoid:

• Treating empirically as BPPV without first excluding central causes 2
• Performing canalith repositioning maneuvers until central pathology is excluded 2
• Assuming peripheral vertigo based solely on patient description rather than timing/triggers 3
• Relying on CT head as adequate imaging for vertigo evaluation 2, 3