What is the initial approach to managing acute vertigo?

Acute Vertigo Management

The initial approach to acute vertigo requires first distinguishing between continuous (acute vestibular syndrome) and episodic presentations, then determining whether the cause is peripheral or central—with BPPV treated by particle repositioning maneuvers, vestibular neuritis managed with vestibular suppressants followed by rehabilitation, and central causes requiring urgent neuroimaging. 1, 2

Initial Clinical Characterization

Timing and Triggers Assessment

• Classify vertigo by duration and pattern: Determine if symptoms are continuous (lasting hours to days) versus episodic (lasting seconds to minutes), and whether triggered by position changes or spontaneous 1, 2
• Continuous vertigo = Acute Vestibular Syndrome (AVS): Sudden onset rotational vertigo lasting 12-36 hours with nausea/vomiting, followed by decreasing disequilibrium over 4-5 days 3
• Episodic vertigo triggered by position = likely BPPV: Brief episodes (seconds to minutes) provoked by head position changes 3

Critical Red Flags for Central Causes

• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) in patients with AVS and visible nystagmus—this requires specific training and should only be used by clinicians trained in its interpretation 4, 1
• Central warning signs requiring urgent MRI: Normal head impulse test (absence of corrective saccade), direction-changing nystagmus without head position changes, vertical skew deviation, or pure downward nystagmus 4, 5
• Additional red flags: Focal neurologic deficits (diplopia, dysarthria, dysphagia, cranial nerve abnormalities), severe gait instability, new headache, or vascular risk factors in patients over 50 years 4, 6

Common pitfall: Emergency physicians without specialized training frequently misapply HINTS testing or use it in inappropriate patient populations, leading to diagnostic errors. As of 2023, HINTS is not standard of care when applied by untrained clinicians 1

Diagnostic Approach by Presentation

For Triggered Episodic Vertigo (Suspected BPPV)

• Perform Dix-Hallpike maneuver to diagnose posterior canal BPPV when vertigo with nystagmus is provoked by the test 3, 1
• If Dix-Hallpike is negative but history compatible with BPPV, perform supine roll test to assess for lateral semicircular canal BPPV 3
• Do NOT order imaging (CT or MRI) or vestibular testing in straightforward BPPV cases unless diagnosis is uncertain or additional symptoms unrelated to BPPV are present 3, 1

For Spontaneous AVS (Continuous Vertigo)

• If trained in HINTS and nystagmus is present: Use HINTS examination to distinguish peripheral from central causes 1
• Add finger rub test to further exclude stroke in patients with nystagmus 1
• If nystagmus is absent: Assess severity of gait unsteadiness—severe instability suggests central pathology 1
• Do NOT use CT brain as it misses posterior fossa strokes in the acute phase and is inadequate for detecting CNS pathology in isolated vertigo 4, 5, 1
• Order MRI brain without and with contrast if HINTS suggests central cause, if clinician untrained in HINTS, or if high clinical suspicion for stroke (MRI detects acute brain lesions in 11% of patients with acute persistent vertigo and no focal deficits) 4, 5

Critical consideration: 75-80% of patients with posterior circulation infarcts causing AVS have no obvious focal neurologic deficits, making clinical assessment challenging 4, 6

For Spontaneous Episodic Vertigo

• Search for symptoms/signs of cerebral ischemia including transient neurologic deficits, visual changes, or speech difficulties 1
• Do NOT use CT brain 1
• Use CT angiography or MRI angiography if concern for transient ischemic attack 1
• Consider vestibular migraine if history of migraine, especially with aural fullness or hearing changes 3

Immediate Management

For BPPV (Posterior Canal)

• Treat with Epley maneuver (particle repositioning maneuver) as first-line therapy 3, 1
• Do NOT routinely prescribe vestibular suppressants (antihistamines or benzodiazepines) for BPPV 3
• May offer vestibular rehabilitation (self-administered or with clinician) or observation with assured follow-up as alternatives 3

For Vestibular Neuritis/Labyrinthitis

• Prescribe meclizine 25-100 mg daily (divided doses) for symptomatic relief of vertigo associated with vestibular system diseases 7
• Warn patients about drowsiness and fall risk, especially in elderly; advise against driving and alcohol use 7
• Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 7
• Consider short-term corticosteroids as a treatment option 1
• Initiate vestibular rehabilitation exercises after acute phase to promote central compensation 8

Important caveat: Vestibular suppressants should only be used for 2-3 days during the acute phase, as prolonged use delays central compensation and recovery 8

For Ménière's Disease

• Acute attack management: Antiemetics for nausea/vomiting, vestibular suppressants for short-term symptom control 3
• Long-term management: Low-salt diet combined with diuretics 8
• Educate patients about episodic nature, potential for hearing loss, and importance of trigger identification 3

Risk Stratification and Follow-up

Factors Modifying Management

• Assess fall risk factors: Impaired mobility/balance, CNS disorders, lack of home support, advanced age 3
• Counsel patients regarding impact on safety, potential for recurrence, and importance of follow-up 3

Reassessment Timeline

• Reassess within 1 month after initial treatment or observation to confirm symptom resolution 3, 6
• Evaluate treatment failures for persistent BPPV, underlying peripheral vestibular disorders, or CNS pathology 3

When to Obtain Urgent Imaging

• Positive Romberg test with vertigo: Indicates central rather than peripheral pathology—obtain urgent MRI brain without and with contrast, do NOT perform Dix-Hallpike as initial maneuver 4
• Do NOT discharge without imaging when Romberg is positive with vertigo 4
• Activate stroke protocol if MRI shows posterior circulation stroke or cerebellar infarct 4

What NOT to Do

• Do NOT treat empirically as BPPV without first excluding central causes when red flags are present 4
• Do NOT rely on CT head as definitive imaging for vertigo presentations 4, 5, 1
• Do NOT use prolonged vestibular suppressants beyond the acute phase (delays compensation) 8
• Do NOT perform routine MRI in straightforward BPPV cases 3, 1
• Do NOT use HINTS examination unless specifically trained in its performance and interpretation 1