What is the best course of treatment for an adult patient with no significant medical history presenting with vertigo?

Treatment of Vertigo in Adults Without Significant Medical History

The best initial approach is to perform the Dix-Hallpike maneuver to diagnose benign paroxysmal positional vertigo (BPPV), which is the most common cause of vertigo, and if positive, treat immediately with canalith repositioning procedures (Epley maneuver) rather than medications. 1, 2

Initial Diagnostic Strategy

Classify by Timing and Triggers

The first step is determining whether vertigo is triggered episodic (seconds to minutes), spontaneous episodic (minutes to hours), or acute continuous (days), as this classification directs both diagnosis and management 2, 3:

• Triggered episodic vertigo (<1 minute): Provoked by specific head position changes suggests BPPV, superior canal dehiscence, or perilymphatic fistula 2
• Spontaneous episodic vertigo (20 minutes to 12 hours): Unprovoked episodes with auditory symptoms (fluctuating hearing loss, tinnitus, aural fullness) suggest Ménière's disease; without auditory symptoms consider vestibular migraine 1, 2
• Acute vestibular syndrome (days): Continuous severe vertigo with nausea/vomiting lasting days suggests vestibular neuritis (no hearing loss) or labyrinthitis (with hearing loss) 1, 2

Perform Targeted Physical Examination

For triggered episodic vertigo, perform the Dix-Hallpike maneuver by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20°, testing each side 1, 3:

• Positive test: Torsional upbeating nystagmus with reproduction of vertigo symptoms confirms posterior canal BPPV 1
• Negative Dix-Hallpike: Perform supine roll test for lateral canal BPPV (10-15% of BPPV cases) by turning head rapidly side-to-side while supine 2

For acute continuous vertigo, perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes, which has 92.9% sensitivity and 83.4% specificity for central pathology 2.

Treatment Algorithm

BPPV (Most Common Cause)

Immediate treatment with canalith repositioning procedures achieves 90-98% success rates 1, 3:

• Perform Epley maneuver (for posterior canal BPPV) or appropriate maneuver for lateral canal BPPV at the time of diagnosis 3
• Do NOT prescribe vestibular suppressants as first-line therapy, as they interfere with natural compensation and are less effective than repositioning 4
• Reassess within 1 month; if symptoms persist, repeat repositioning maneuvers (success reaches 90-98% with additional sessions) 1

Vestibular Suppressants: Limited Role Only

Vestibular suppressants should only be offered for short-term symptom management during acute Ménière's disease attacks, NOT as primary BPPV treatment 1:

• Meclizine 25-100 mg daily in divided doses for acute vertigo episodes only 5
• Critical caveat: All benzodiazepines carry significant dependence risk; anticholinergics cause blurred vision, dry mouth, urinary retention, and sedation 1
• Never use long-term, as they impair central vestibular compensation 4

Ménière's Disease

For spontaneous episodic vertigo with auditory symptoms (fluctuating hearing loss, tinnitus, aural fullness) lasting 20 minutes to 12 hours 1:

• Dietary sodium restriction and adequate hydration as first-line management 1
• Avoid excessive caffeine, alcohol, and nicotine 1
• Consider diuretics for symptom reduction 6
• Vestibular suppressants only during acute attacks, not for prevention 1

Vestibular Neuritis/Labyrinthitis

For acute continuous vertigo lasting days 1:

• Initial vestibular suppressants for 2-3 days maximum during acute phase 6
• Early vestibular rehabilitation exercises (within days) to promote central compensation 6, 7
• Labyrinthitis (with hearing loss) may require additional evaluation for infectious causes 1

Red Flags Requiring Urgent Imaging

Order urgent MRI brain without and with IV contrast if any of the following are present 2:

• Positive Romberg test (indicates central pathology) 2
• Severe postural instability or inability to walk 2
• Focal neurologic deficits (cranial nerve palsies, limb weakness, dysarthria) 2
• Central nystagmus patterns on HINTS examination 2
• Age >50 with vascular risk factors 2
• Critical pitfall: Up to 75-80% of posterior circulation strokes causing vertigo lack focal neurologic deficits initially, so maintain high suspicion 2

Treatment Failures and Reassessment

Reevaluate within 1 month after initial treatment 1:

• If Dix-Hallpike remains positive, repeat canalith repositioning maneuvers 1
• After 2-3 failed repositioning attempts, obtain MRI to exclude CNS disorders, as 3% of BPPV treatment failures harbor underlying CNS pathology 1, 2
• Consider coexisting vestibular conditions or conversion to different canal involvement 1

Patient Education and Safety

Counsel all patients on fall risk and BPPV recurrence 1:

• BPPV recurrence rate is 15% per year, reaching 37-50% at 5 years 1
• Instruct patients to sit or lie down immediately when dizzy and avoid driving during acute episodes 4
• Post-traumatic BPPV has higher recurrence rates and more refractory symptoms 4
• Patients should return promptly if symptoms recur for repeat repositioning 1

Common Pitfalls to Avoid

• Do not assume normal neurologic exam excludes stroke, as most posterior circulation strokes initially lack focal deficits 2
• Do not prescribe vestibular suppressants as first-line BPPV treatment instead of repositioning maneuvers 4
• Do not order routine blood tests or CT head for typical BPPV presentations, as diagnosis is clinical 2, 3
• Do not rely solely on patient's description of "spinning"; focus on timing and triggers for accurate classification 2