What is the initial approach to treating vertigo?

Initial Approach to Treating Vertigo

The initial approach to vertigo depends critically on distinguishing peripheral from central causes through timing and triggers, followed by targeted physical examination maneuvers—with canalith repositioning procedures as first-line treatment for BPPV (the most common cause), while avoiding routine use of vestibular suppressant medications. 1, 2

Step 1: Classify by Timing and Triggers

Before initiating any treatment, classify the vertigo syndrome to guide your approach 3:

• 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): Consider Ménière's disease, vestibular migraine, or vertebrobasilar insufficiency—unprovoked episodes lasting 20 minutes to hours 3
• Acute vestibular syndrome (days): May indicate 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 Requiring Urgent Imaging

Do not proceed with BPPV treatment if any central warning signs are present 2:

• Positive Romberg test (indicates central pathology, not peripheral) 2
• Severe postural instability 3
• Cranial nerve deficits 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

If any red flags present: Order urgent MRI brain without and with IV contrast immediately 2, 3. Do not perform Dix-Hallpike or treat empirically as BPPV until central pathology is excluded 2.

Step 3: Perform Diagnostic Maneuvers (If No Red Flags)

For Posterior Canal BPPV (Most Common)

Perform the Dix-Hallpike maneuver: Bring patient from upright to supine with head turned 45° to one side and neck extended 20° with affected ear down 1. Diagnose posterior canal BPPV when torsional, upbeating nystagmus is provoked 1. Repeat with opposite ear down if initial maneuver is negative 1.

For Lateral Canal BPPV

If Dix-Hallpike shows horizontal or no nystagmus: Perform supine roll test to assess for lateral semicircular canal BPPV, which accounts for 10-15% of BPPV cases 1, 3.

Step 4: Initial Treatment Based on Diagnosis

For BPPV (Triggered Episodic Vertigo)

Treat with canalith repositioning procedure (CRP) immediately—this is a strong recommendation 1. Do not offer vestibular suppressant medications as routine treatment 1. Cure rates reach 86-100% with up to 4 CRP treatments for lateral canal BPPV 1.

Do not recommend postprocedural postural restrictions after CRP for posterior canal BPPV 1. This is a strong recommendation against a previously common practice.

Alternatively, observation with follow-up may be offered as initial management, as BPPV has high spontaneous resolution rates 1.

For Acute Vestibular Syndrome (Spontaneous Continuous Vertigo)

If peripheral cause confirmed (vestibular neuritis/labyrinthitis), vestibular rehabilitation may be offered, either self-administered or with a clinician 1.

Medication Use: When and What NOT to Do

Do not routinely treat BPPV with vestibular suppressant medications such as antihistamines (meclizine) and/or benzodiazepines 1. While meclizine is FDA-approved for vertigo associated with vestibular system diseases 4, the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine use in BPPV 1.

Meclizine (25-100 mg daily in divided doses) may cause drowsiness and has anticholinergic effects, requiring caution in patients with asthma, glaucoma, or prostate enlargement 4. Reserve pharmacotherapy for acute spontaneous vertigo syndromes, not positional vertigo 5.

Step 5: Reassessment Protocol

Reassess patients within 1 month after initial observation or treatment to document resolution or persistence of symptoms 1. This is critical because:

• Treatment failure may indicate canal conversion (posterior to lateral or vice versa, occurring in ~6% of cases) 1
• CNS disorders masquerade as BPPV in 3% of treatment failures 1
• Coexisting vestibular dysfunction may be present, particularly after head trauma or vestibular neuritis 1

If symptoms persist: Repeat the appropriate positional testing (Dix-Hallpike or supine roll test) and evaluate for unresolved BPPV, involvement of different semicircular canals, or underlying peripheral vestibular or central nervous system disorders 1.

Common Pitfalls to Avoid

• Assuming normal neurologic exam excludes stroke: 75-80% of posterior circulation strokes causing vertigo lack focal neurologic deficits initially 3
• Performing Dix-Hallpike when Romberg is positive: This indicates central pathology requiring imaging first, not BPPV testing 2
• Relying on patient's description of "spinning": Focus on timing and triggers instead, which are more diagnostically useful 3
• Ordering routine imaging or vestibular testing: Do not obtain radiographic imaging or vestibular testing in patients who meet diagnostic criteria for BPPV in the absence of additional signs/symptoms inconsistent with BPPV 1

Patient Education

Educate patients regarding the impact of BPPV on their safety (particularly fall risk), the potential for disease recurrence, and the importance of follow-up 1. This is especially critical in older persons with Menière's disease or migraine, who have greater chance for BPPV recurrence and increased fall risk 1.