What are the treatment options for an adult patient with no significant medical history presenting with vertigo?

Treatment of Vertigo in Adults

For an adult with vertigo and no significant medical history, immediately perform the Dix-Hallpike maneuver to diagnose BPPV—if positive, treat with the Epley maneuver as first-line therapy, which has 80-93% success rates and is superior to medications. 1

Initial Diagnostic Approach

Before initiating treatment, classify the vertigo pattern based on timing and triggers to guide management 2:

• Triggered episodic vertigo (<1 minute): Suggests BPPV, provoked by specific head position changes 2
• Spontaneous episodic vertigo (minutes to hours): Consider Ménière's disease or vestibular migraine, with unprovoked episodes lasting 20 minutes to hours 2
• Acute vestibular syndrome (days): Indicates vestibular neuritis or labyrinthitis, with continuous severe vertigo 2
• Chronic vertigo (weeks to months): May suggest medication effects or other systemic causes 2

Confirm true vertigo by asking if the patient feels spinning or rotation—vague "dizziness" or lightheadedness suggests non-vestibular causes. 3, 4

Physical Examination Maneuvers

Perform the Dix-Hallpike maneuver for all patients with suspected BPPV, as this is the most common cause of vertigo (85-95% of cases) 2:

• Positive test shows torsional, upbeating nystagmus 4
• May require repeat testing at a separate visit to avoid false-negatives 2
• If negative but history compatible with BPPV, perform Supine Roll Test for lateral canal BPPV (10-15% of cases) 2

Check for red flags indicating central causes requiring urgent imaging 1, 2:

• Downbeating nystagmus without torsional component 1
• Direction-changing nystagmus without head position changes 1
• Severe postural instability or focal neurologic deficits 2
• Age >50 with vascular risk factors 2

Treatment by Diagnosis

Benign Paroxysmal Positional Vertigo (BPPV)

The Epley maneuver is definitive first-line treatment with 80-93% success after 1-3 treatments, vastly superior to medications (78.6-93.3% vs 30.8% efficacy). 1

Do not use vestibular suppressant medications as primary treatment for BPPV. 1 Meclizine may only be considered for:

• Severe nausea/vomiting during the maneuver itself 1
• Patients who refuse repositioning 1
• Maximum duration: 3-5 days only 1

Meclizine dosing when indicated: 25-100 mg daily in divided doses 5, but use with extreme caution due to:

• Drowsiness and cognitive deficits, particularly in elderly 1, 5
• Anticholinergic effects and increased fall risk 1
• Contraindicated in asthma, glaucoma, or prostate enlargement 1, 5
• Impairs driving ability 5

Ménière's Disease

First-line preventive therapy combines dietary sodium restriction (1500-2300 mg daily) with diuretics. 1 Additional management includes:

• Acute vertigo attacks: Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) 1
• Limit alcohol and caffeine intake 1
• Consider betahistine to increase inner ear vasodilation 1

Diagnosis requires episodic vertigo lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, or aural fullness. 2 Distinguish from vestibular migraine, which may have:

• Shorter (<15 minutes) or longer (>24 hours) episodes 3
• Visual auras and photophobia 3
• Motion intolerance 3
• Mild or absent hearing loss that remains stable 3

Vestibular Neuritis/Labyrinthitis

Acute vestibular neuritis presents with severe continuous vertigo lasting 12-36 hours, followed by decreasing disequilibrium for 4-5 days, without hearing loss. 3 Treatment includes:

• Initial vestibular suppressants for symptom control (short-term only) 6
• Early vestibular rehabilitation exercises 6

Labyrinthitis differs by including profound hearing loss with the vertigo. 3

Vestibular Rehabilitation

Vestibular rehabilitation is indicated for 1:

• Persistent dizziness from any vestibular cause
• Chronic imbalance or incomplete recovery
• Can be self-administered or therapist-directed

Follow-Up and Safety

Reassess within 1 month after initial treatment to document resolution or persistence. 1 Counsel patients on:

• Fall risk, especially in elderly on vestibular suppressants 1
• BPPV recurrence rates 4
• Importance of reporting atypical symptoms 4

If no improvement with repositioning maneuvers or atypical presentation, obtain MRI brain to exclude central causes, as 3% of BPPV treatment failures have CNS disorders masquerading as BPPV. 2

Critical Pitfalls to Avoid

• Never assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes causing vertigo lack focal deficits initially 2
• Do not rely on patient's description of "spinning" alone—focus on timing and triggers for diagnosis 2
• Avoid prolonged vestibular suppressant use—these medications delay central compensation and worsen long-term outcomes 1
• Do not perform Dix-Hallpike if Romberg test is positive—this indicates central pathology requiring imaging first 2