What is the appropriate management for a 27-year-old male with acute vertigo, nausea, and vomiting, and a history of possible inner ear infection, now presenting with mild ear pressure and dizziness exacerbated by head movement?

Management of Acute Vertigo with Head Movement Provocation

This patient most likely has benign paroxysmal positional vertigo (BPPV) and should be treated with the Epley maneuver (canalith repositioning procedure) as first-line therapy, NOT with medications like meclizine. 1

Clinical Reasoning and Diagnosis

The clinical presentation strongly suggests BPPV based on several key features:

• Dizziness recreated with turning of head is the hallmark of positional vertigo 2
• Short-duration vertigo episodes (described as "like being hungover" rather than continuous spinning) 2
• No hearing loss, tinnitus, or aural fullness on examination, which distinguishes this from Ménière's disease 2
• Normal neurologic examination rules out central causes like stroke 2
• Single episode of vomiting is consistent with acute vestibular stimulation 1

The chronic nasal congestion and bilateral erythematous nares/turbinates are likely unrelated to the acute vertigo presentation and may represent chronic rhinitis. 1

The history of possible ear infection 5-10 years ago is not relevant to current management, as the current ear examination is normal. 1

First-Line Treatment: Canalith Repositioning

Perform the Epley maneuver immediately - this achieves 80% vertigo resolution with only 1-3 treatments, compared to only 30.8% improvement with medication alone. 1, 3

Pre-Procedure Counseling

Before performing the maneuver, warn the patient that: 1

• He will experience sudden intense vertigo lasting up to 60 seconds during the procedure
• Nausea may occur (happens in approximately 12% of patients)
• A falling sensation may occur within 30 minutes after completion
• Symptoms will subside quickly and the procedure has high success rates

Managing Nausea During the Procedure

If severe nausea occurs during the Epley maneuver: 1

• Move slowly between positions
• Maintain each position for the full 20-30 seconds to allow symptoms to subside
• Consider pre-medicating with ondansetron (not meclizine) only if the patient has a history of severe motion sickness or if he previously experienced severe nausea during repositioning

Ondansetron is superior to promethazine for nausea control with fewer side effects, though promethazine may be more effective for vertigo itself. 4 However, neither should be used as primary treatment for BPPV. 1

Why NOT Meclizine

The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends AGAINST routine treatment of BPPV with meclizine or other vestibular suppressants. 1

Critical reasons to avoid meclizine in this patient: 1, 5

• No evidence that vestibular suppressants are effective as definitive treatment for BPPV
• Canalith repositioning has 78.6-93.3% improvement versus only 30.8% with medication alone
• Patients who underwent repositioning maneuvers alone recovered faster than those receiving concurrent vestibular suppressants
• Meclizine causes drowsiness and cognitive deficits that interfere with this active duty service member's ability to perform duties
• Vestibular suppressants can interfere with central compensation and prolong recovery

Very Limited Role for Meclizine

Meclizine may only be considered in BPPV for: 1

• Short-term management of severe autonomic symptoms (severe nausea/vomiting) in highly symptomatic patients
• Prophylaxis for patients who previously had severe nausea during repositioning maneuvers
• Patients who refuse other treatment options

If used at all, prescribe meclizine 25 mg as-needed (NOT scheduled) for severe nausea only, and discontinue as soon as possible. 1, 3

Alternative Diagnosis Considerations

While BPPV is most likely, briefly consider and rule out:

Vestibular neuritis would present with: 2

• Severe rotational vertigo lasting 12-36 hours (not brief episodes)
• Prolonged nausea and vomiting
• No hearing loss (consistent with this case)
• Gradual improvement over 4-5 days

Vestibular migraine would present with: 2

• Attacks lasting hours (not seconds to minutes)
• History of migraines
• Photophobia more prominent than in this case

Labyrinthitis would present with: 2

• Profound hearing loss (absent in this case)
• Prolonged vertigo >24 hours (not brief positional episodes)

The normal neurologic exam rules out stroke, which would typically show dysarthria, dysphagia, or other focal neurologic signs. 2

Follow-Up and Prognosis

Reassess within 1 month to document symptom resolution or persistence. 1, 3

Counsel the patient that: 5

• BPPV recurrence rates are 10-18% at 1 year and may reach 36% over time
• If symptoms recur, the Epley maneuver can be repeated with similar success rates
• If symptoms persist despite 2-3 repositioning attempts, consider vestibular rehabilitation therapy

Common Pitfalls to Avoid

• Do not prescribe meclizine as primary treatment - this delays definitive therapy and may prolong symptoms 1
• Do not perform imaging unless red flags are present (abnormal neurologic exam, severe headache, focal deficits) 1, 5
• Do not attribute symptoms to the chronic nasal congestion - these are separate issues 1
• Do not delay the Epley maneuver to "try medication first" - this is outdated practice 1, 3