What could be causing a 5-day history of vertigo (dizziness) in a male, particularly when laying flat and rotating at night, with worsening symptoms in the morning?

Benign Paroxysmal Positional Vertigo (BPPV)

This clinical presentation is classic for BPPV—the most common cause of vertigo—and should be diagnosed with the Dix-Hallpike maneuver and treated immediately with canalith repositioning procedures (Epley maneuver), which have an 80% success rate with 1-3 treatments. 1

Clinical Diagnosis

The symptoms described are pathognomonic for BPPV 1, 2:

• Positional triggers: Vertigo provoked by laying flat and rotating at night indicates displacement of calcium carbonate crystals (otoconia) in the semicircular canals 1
• Morning exacerbation: Worst symptoms upon waking are typical, as accumulated head movements during sleep trigger crystal displacement 1
• Brief duration: BPPV episodes last seconds to less than 1 minute per position change 2
• 5-day history: BPPV naturally becomes less severe over time; the first episode is typically the worst 1

Perform the Dix-Hallpike maneuver immediately to confirm the diagnosis—this bedside test moves the head into positions that make crystals move, producing characteristic torsional nystagmus 1, 2. Normal imaging and laboratory tests cannot diagnose BPPV 1.

Immediate Treatment

Do NOT prescribe vestibular suppressants (meclizine, diazepam) as primary treatment—they interfere with central compensation and increase fall risk 2. While meclizine is FDA-approved for vertigo 3, guidelines explicitly recommend against its use as primary BPPV treatment 2.

Perform the canalith repositioning procedure (Epley maneuver) at the same visit as diagnosis 1, 2:

• This bedside maneuver guides crystals back to their original location in the inner ear 1
• Success rate is approximately 80% with only 1-3 treatments 1
• Can be performed immediately after diagnostic testing 1

Red Flags Requiring Urgent Evaluation

Before assuming BPPV, exclude central causes that require emergency intervention 1, 4:

• Neurological deficits: Dysarthria, dysphagia, dysmetria, sensory/motor loss, or Horner's syndrome indicate brainstem or cerebellar stroke 1, 4
• Atypical nystagmus: Downbeating nystagmus without torsional component, direction-changing nystagmus without head position changes, or baseline nystagmus without provocative maneuvers suggest central pathology 1, 4
• Severe imbalance: Inability to stand or walk disproportionate to vertigo severity 4
• Persistent symptoms: Vertigo lasting more than 24 hours without improvement requires immediate attention 4

Note: 10% of cerebellar strokes present identically to peripheral vestibular processes, and up to 75-80% of posterior circulation strokes may have no focal neurologic deficits 1, 2.

Assessment for Modifying Factors

Evaluate for factors that complicate BPPV management 1:

• Impaired mobility or balance increases fall risk (12-fold increase in falls among older individuals with dizziness) 1
• CNS disorders or history of head trauma (posttraumatic BPPV requires repeated treatments in 67% of cases versus 14% for idiopathic BPPV) 1
• Lack of home support for performing home repositioning exercises 1

Follow-Up Management

If symptoms persist after repositioning maneuvers, reconsider the diagnosis—failure to respond to canalith repositioning should raise concern that the underlying diagnosis may not be BPPV 1.

Educate the patient about atypical symptoms that warrant further evaluation 1:

• Subjective hearing loss, gait disturbance, non-positional vertigo, or persistent nausea/vomiting after BPPV resolution may indicate concurrent vestibular or CNS disorders 1

Vestibular rehabilitation therapy should be considered only if incomplete recovery occurs after repositioning procedures 2.