What is the best initial treatment for a patient with dizziness, especially with movement, and a corrective saccade on the head impulse test, suggesting a vestibular issue?

Treatment Recommendation for Vestibular Neuritis

This patient should be started on meclizine for symptomatic relief of his acute vestibular neuritis, not for BPPV treatment. 1, 2

Clinical Reasoning: This is NOT BPPV

The clinical presentation clearly indicates vestibular neuritis, not benign paroxysmal positional vertigo (BPPV), based on several key features:

• Continuous dizziness lasting two days (not brief episodic vertigo) 3, 4
• Always present, not just with position changes - BPPV causes brief episodes (<1 minute) triggered by specific head movements 5, 3
• Positive head impulse test with corrective saccade - this indicates peripheral vestibular dysfunction (vestibular neuritis), not BPPV 3, 4
• Unidirectional nystagmus - consistent with acute peripheral vestibulopathy 4
• Negative Dix-Hallpike maneuver - rules out posterior canal BPPV 5, 1
• Recent viral prodrome (roommate's cold two weeks ago) - classic trigger for vestibular neuritis 4

Why Each Option is Right or Wrong

Start Meclizine (CORRECT)

Meclizine is FDA-approved for vertigo associated with vestibular system diseases and is appropriate for acute vestibular neuritis. 2 While the American Academy of Otolaryngology-Head and Neck Surgery recommends against vestibular suppressants for BPPV specifically 5, this patient has vestibular neuritis, where vestibular sedatives are indicated for symptom relief during the acute phase 6, 7, 4

Perform Epley Maneuver (INCORRECT)

The Epley maneuver is only indicated for posterior canal BPPV with a positive Dix-Hallpike test 5, 1. This patient has a negative Dix-Hallpike, making BPPV unlikely and the Epley maneuver inappropriate 5. The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that imaging evaluation in BPPV with typical nystagmus on Dix-Hallpike testing is unnecessary, but conversely, patients with negative or atypical Dix-Hallpike testing are at increased risk of having central causes 5

Start Lorazepam (LESS OPTIMAL)

While benzodiazepines can suppress vestibular symptoms, they interfere with central compensation mechanisms and carry risks of drowsiness, cognitive deficits, and falls, especially in young patients 5, 1. Meclizine is preferred as it has fewer adverse effects while providing adequate symptom relief 2, 7

Start Hydrochlorothiazide (INCORRECT)

Hydrochlorothiazide is used for Ménière's disease, which presents with episodic vertigo (20 minutes to 12 hours), fluctuating hearing loss, tinnitus, and ear fullness 3, 7. This patient has continuous vertigo for two days without hearing loss, making Ménière's disease unlikely 3

Critical Management Points

Immediate actions:

• Start meclizine for symptomatic relief of acute vestibular neuritis 2, 7
• Reassess within 1 month to confirm symptom resolution 5, 1
• Consider vestibular rehabilitation therapy after the acute phase to facilitate central compensation 4

Red flags requiring urgent imaging:

• If symptoms worsen or new neurologic deficits develop, obtain urgent MRI brain without and with IV contrast to exclude posterior circulation stroke 5, 3
• The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 92.9% sensitivity for detecting central causes when performed by trained clinicians 3

Common Pitfall to Avoid

Do not misdiagnose all positional dizziness as BPPV. 5, 3 The key distinguishing features are:

• BPPV: Brief episodes (<1 minute) triggered by specific position changes, positive Dix-Hallpike 5, 3
• Vestibular neuritis: Continuous vertigo lasting days, positive head impulse test, negative Dix-Hallpike 3, 4

Up to 3% of patients initially diagnosed with BPPV are later found to have CNS disorders 5, emphasizing the importance of accurate initial diagnosis based on timing, triggers, and physical examination findings 3, 7