What are the causes and treatments of dizziness and vomiting with head movement and changes in position?

Causes and Management of Positional Dizziness with Vomiting

Benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness and vomiting triggered by head movement and position changes, accounting for approximately 42% of vertigo cases in primary care settings. 1

Primary Cause: BPPV

BPPV occurs when calcium carbonate crystals (otoconia) dislodge from the otolith membranes and float freely within the semicircular canals or adhere to the cupula. 1, 2 When you change head position, these crystals move and create false signals of violent spinning, triggering:

• Brief episodes of intense vertigo lasting seconds to less than 1 minute 1
• Nausea and vomiting during episodes 1
• Severe disorientation in space 1
• Symptoms triggered by specific movements: lying down, rolling over in bed, looking up, bending over 1

Diagnostic Confirmation

The Dix-Hallpike maneuver is the gold standard diagnostic test and should be performed at the bedside. 1, 3 Positive findings include:

• 5-20 second latency before symptoms begin 3
• Torsional, upbeating nystagmus toward the affected ear 3
• Vertigo and nystagmus that increase then resolve within 60 seconds 3

No imaging or laboratory testing is indicated for typical BPPV presentations. 3

Other Peripheral Causes to Consider

Vestibular Migraine

Look for headache, photophobia, and phonophobia accompanying the vertigo episodes. 1, 3 Episodes typically last minutes to hours rather than seconds. 1

Ménière's Disease

Distinguished by fluctuating hearing loss, aural fullness, and tinnitus in the affected ear, with episodes lasting 20 minutes to hours. 1, 4 This is not triggered by position changes alone. 1

Superior Canal Dehiscence

Vertigo is induced by pressure changes (Valsalva, loud sounds) rather than position changes alone. 1 May present with conductive hearing loss. 1

Central Causes (Red Flags)

While BPPV is benign, central causes can be life-threatening and must be excluded. 1

Posterior Circulation Stroke

Critical pitfall: 75-80% of patients with posterior circulation infarcts have no focal neurologic deficits on standard examination. 3, 5 Red flags requiring urgent MRI include:

• New severe headache accompanying dizziness 3
• Inability to stand or walk 3
• Downbeating nystagmus or other central nystagmus patterns 3
• Focal neurological deficits 3

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, superior to early MRI (46% sensitivity). 1, 3 However, this examination is less reliable when performed by non-experts. 1, 3

Central Paroxysmal Positional Vertigo (CPPV)

Rare but serious condition that mimics BPPV but originates from brainstem or cerebellar pathology. 1 Suspect when:

• Nystagmus patterns are atypical (downbeating, purely horizontal without torsional component) 6
• No latency period before nystagmus onset 6
• Symptoms persist beyond 60 seconds 6

Treatment Algorithm

For Confirmed BPPV

Canalith repositioning procedures (Epley maneuver) are first-line treatment with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1, 3, 5

• Perform the Epley maneuver immediately at the bedside 1
• Medications are not indicated except for immediate relief of severe nausea 1
• Reassess within one month if symptoms persist 1, 3

For Treatment Failures

If symptoms persist after initial repositioning, repeat the Dix-Hallpike test to confirm persistent BPPV versus an alternative diagnosis. 1 Consider:

• Additional repositioning maneuvers (success rate reaches 90-98%) 1, 5
• Vestibular rehabilitation therapy for persistent imbalance 1, 3
• Reevaluation for coexisting vestibular or central nervous system disorders 1

When to Image

MRI brain without contrast is indicated for: 1, 3

• Abnormal neurologic examination 1
• HINTS examination suggesting central cause 1
• High vascular risk patients with acute vestibular syndrome 3
• Unilateral or pulsatile tinnitus 3
• Asymmetric hearing loss 3
• Failure to respond to appropriate BPPV treatment 1, 3

CT head has very low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts. 3, 5

Common Pitfalls to Avoid

Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing (seconds vs minutes vs hours) and specific triggers (position change vs spontaneous). 1, 3, 5

Do not assume a normal neurologic exam excludes stroke—most posterior circulation strokes present without focal deficits. 3, 5

Do not order routine imaging for straightforward BPPV with positive Dix-Hallpike—it delays effective treatment and has extremely low yield. 3, 5

Do not use CT when stroke is suspected—it has only 20-40% sensitivity for causative pathology in dizziness. 3

Associated Risk Factors

Most BPPV cases occur spontaneously, but can be associated with: 1

• Trauma 1
• Migraine 1
• Other inner ear problems 1
• Diabetes 1
• Osteoporosis 1
• Prolonged bed rest or preferred sleep side 1

BPPV is more common in older adults and increases fall risk, particularly in seniors who should seek prompt treatment. 1