What is the appropriate management for a patient presenting with dizziness (vertigo) upon movement, nausea, and vomiting, without chest pain or other complaints?

Management of Acute Vertigo with Movement, Nausea, and Vomiting

This 27-year-old patient most likely has benign paroxysmal positional vertigo (BPPV) and should undergo immediate bedside Dix-Hallpike testing to confirm the diagnosis, followed by canalith repositioning procedures (Epley maneuver) if positive—no imaging or laboratory testing is needed for typical presentations. 1

Initial Clinical Assessment

Critical Red Flag Screening

Before proceeding with BPPV evaluation, you must actively exclude dangerous central causes by assessing for:

• Neurological deficits: Speech difficulties (dysarthria/dysphasia), motor weakness, sensory changes, visual disturbances, difficulty swallowing, or Horner's syndrome—any of these mandate immediate stroke evaluation 2
• Severe imbalance: Inability to stand or walk that is disproportionate to the vertigo suggests central pathology 2, 3
• Atypical nystagmus: Direction-changing or downbeating nystagmus without head position changes indicates central vertigo 2, 3
• Severe headache: New-onset severe or occipital headache with vertigo requires urgent imaging 2, 3
• Hearing loss: Sudden unilateral hearing loss or tinnitus suggests alternative diagnoses like Menière disease or posterior circulation stroke 1, 3

In this case, the absence of chest pain, neurological symptoms, and "other complaints" suggests a peripheral (benign) cause, making BPPV the leading diagnosis. 1

Diagnostic Approach

Bedside Testing for BPPV

Perform the Dix-Hallpike maneuver immediately—this is the gold standard diagnostic test with the following positive criteria: 1, 3

• Latency period of 5-20 seconds before symptoms begin
• Torsional, upbeating nystagmus toward the affected ear
• Provoked vertigo and nystagmus that increase then resolve within 60 seconds
• Symptoms lasting less than 1 minute per episode

If the Dix-Hallpike test is positive with typical findings, no imaging, laboratory testing, or vestibular function testing is required. 1, 3 The ACR Appropriateness Criteria explicitly state that imaging evaluation in BPPV with typical nystagmus on Dix-Hallpike testing is unnecessary, as the positivity rate of head CT in emergency departments for all dizziness complaints is only approximately 2%. 1

When to Consider Alternative Diagnoses

If symptoms are persistent (lasting hours to days) rather than brief episodes, this represents acute vestibular syndrome (AVS) and requires different evaluation: 1

• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you have specialized training—this has 100% sensitivity for detecting stroke when properly performed 1, 3
• HINTS findings suggesting peripheral cause: Abnormal head impulse test, unidirectional horizontal nystagmus, no skew deviation 3, 4
• HINTS findings suggesting central cause: Normal head impulse test, direction-changing nystagmus, or skew deviation present—these require immediate MRI 3, 5

Critical pitfall: 75-80% of patients with posterior circulation stroke from acute vestibular syndrome have NO focal neurologic deficits on examination, so a normal neurologic exam does not exclude stroke in persistent vertigo. 3 However, this patient's movement-triggered symptoms strongly favor BPPV over AVS.

Immediate Treatment

Canalith Repositioning Procedure

If Dix-Hallpike is positive, immediately perform the Epley maneuver—this is first-line treatment with: 1, 3

• 80% success rate after 1-3 treatments
• 90-98% success with repeat maneuvers if initial treatment fails
• Significantly superior to observation or Brandt-Daroff exercises (80.5% vs 25% negative Dix-Hallpike by day 7)

Symptomatic Management

Medications are NOT indicated for typical BPPV treatment—they only provide temporary symptom relief and do not address the underlying crystal displacement. 1 However, for severe acute nausea during the procedure, you may use:

• Antihistamines (meclizine, dimenhydrinate) for immediate distress only 4, 6
• Avoid prolonged vestibular suppressant use as it delays central compensation

Follow-Up and Patient Counseling

Expected Course

Counsel the patient that: 1

• During the Epley maneuver, they may experience brief intense vertigo and nausea
• Following treatment, mild motion sensitivity or instability may persist for hours to days
• BPPV naturally becomes less severe over time even without treatment
• The first episode is typically the worst, with subsequent episodes being milder

When to Return

Instruct the patient to return immediately if: 2, 3

• Symptoms persist beyond 24 hours without improvement
• New neurological symptoms develop (speech changes, weakness, visual disturbances)
• Severe headache develops
• Hearing loss or tinnitus occurs
• Inability to walk or stand develops

Recurrence Management

Reassess within one month to document symptom resolution, and educate that: 3

• BPPV can recur and repeat repositioning procedures are effective
• Fall risk is elevated during symptomatic periods, especially in elderly patients
• If symptoms fail to resolve after appropriate repositioning attempts, vestibular rehabilitation therapy is indicated

Imaging Decisions

No imaging is indicated for this patient if the presentation is typical for BPPV with positive Dix-Hallpike and no red flags. 1, 3 The diagnostic yield of CT in isolated dizziness is less than 1%, and even MRI has only 4% positivity in isolated dizziness without neurological findings. 1, 3

MRI brain without contrast is indicated only if: 1, 5

• Abnormal neurological examination is present
• HINTS examination suggests central cause (when performed by trained examiner)
• High vascular risk factors with acute vestibular syndrome
• Atypical BPPV that fails to respond to appropriate repositioning
• Unilateral hearing loss or pulsatile tinnitus accompanies vertigo

CT head without contrast has poor sensitivity (20-40%) for posterior circulation pathology and should not be used instead of MRI when stroke is suspected. 3, 5 It may serve only as a rapid initial screen when MRI is unavailable and stroke is strongly suspected.