How to manage vertigo in a patient, considering their potential history of Benign Paroxysmal Positional Vertigo (BPPV) or Meniere's disease?

Management of Vertigo

For BPPV, perform the canalith repositioning procedure (Epley maneuver) immediately upon diagnosis—this is the definitive first-line treatment with 80-98% success rates, and vestibular suppressant medications should NOT be routinely prescribed. 1, 2

Diagnostic Algorithm

Step 1: Identify the Type of Vertigo

For suspected BPPV (most common cause):

• Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV (85-95% of cases): bring patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus 1
• If Dix-Hallpike shows horizontal or no nystagmus but history suggests BPPV, perform the supine roll test for lateral canal BPPV (10-15% of cases) 1
• Do NOT order imaging or vestibular testing unless there are atypical neurological signs (abnormal cranial nerves, severe headache, visual disturbances) 1, 2

Before proceeding with treatment, assess for modifying factors:

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Increased fall risk (BPPV increases fall risk 12-fold, especially in elderly) 1, 2

Treatment Protocol for BPPV

Posterior Canal BPPV (Most Common)

Perform the Epley maneuver immediately:

1. Patient seated upright, head turned 45° toward affected ear 2, 3
2. Rapidly move to supine with head hanging 20° below horizontal for 20-30 seconds 2, 3
3. Turn head 90° to unaffected side, hold 20-30 seconds 2, 3
4. Turn head and body another 90° (face down position), hold 20-30 seconds 2, 3
5. Return to sitting position 2, 3

Critical post-procedure instructions:

• Patients can resume normal activities immediately—do NOT recommend postprocedural restrictions (strong evidence shows no benefit and may cause unnecessary complications) 1, 2

Alternative for posterior canal BPPV:

• Semont (Liberatory) maneuver: 94.2% resolution at 6 months 2

Lateral (Horizontal) Canal BPPV

For geotropic variant:

• Barbecue Roll (Lempert) maneuver: roll patient 360° in sequential 90° steps, success rate 50-100% 2, 4
• Gufoni maneuver: patient moves from sitting to side-lying on unaffected side for 30 seconds, then quickly turn head 45-60° toward ground for 1-2 minutes, success rate 93% 2, 4

For apogeotropic variant:

• Modified Gufoni maneuver: patient lies on affected side instead 2

Medication Management

DO NOT routinely prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines):

• No evidence of effectiveness as definitive treatment for BPPV 1, 2, 3
• Cause significant adverse effects: drowsiness, cognitive deficits, increased fall risk 2, 5
• Interfere with central compensation mechanisms 2

Limited exception:

• May consider ONLY for short-term management (1-3 days) of severe nausea/vomiting in severely symptomatic patients 2, 3
• Meclizine FDA-approved for vertigo associated with vestibular system diseases, but guideline evidence supersedes this for BPPV specifically 5

Follow-Up and Treatment Failures

Reassess within 1 month to confirm symptom resolution 1, 2, 3

If symptoms persist after initial treatment:

1. Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV 2
2. Perform additional repositioning maneuvers—repeat CRP achieves 90-98% success rates 2, 4, 3
3. Check for canal conversion (occurs in 6-7% of cases): posterior may convert to lateral or vice versa 1, 2, 3
4. Evaluate for multiple canal involvement (rare but possible) 2
5. Rule out coexisting vestibular dysfunction if symptoms occur with general head movements or spontaneously 2
6. Consider CNS disorders masquerading as BPPV if atypical features present (especially after 2-3 failed properly performed maneuvers): obtain thorough neurological exam and consider MRI of brain/posterior fossa 1, 2

Adjunctive Vestibular Rehabilitation

May offer vestibular rehabilitation therapy (VRT) as adjunct, NOT substitute for CRP:

• Particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful CRP 2, 4
• Reduces recurrence rates by approximately 50% 2
• Patients treated with CRP plus VRT show significantly improved gait stability compared to CRP alone 2

VRT components:

• Habituation exercises: repeat movements provoking vertigo until symptoms fatigue 4, 6
• Adaptation exercises: head-eye movements with various body postures 4, 6
• Balance training: maintaining balance with reduced support base 4, 6
• Brandt-Daroff exercises: significantly less effective than CRP (24% vs 80.5% success at 1 week) but may be used for patients with contraindications to CRP 2, 4

For patients unable to perform standard maneuvers:

• Severe cervical stenosis or radiculopathy 2
• Severe rheumatoid arthritis or ankylosing spondylitis 2
• Morbid obesity 2
• Limited cervical range of motion 1, 2

Management of Meniere's Disease

If vertigo is due to Meniere's disease (not BPPV):

• Treatment goals: reduce severity/frequency of vertigo attacks, relieve associated symptoms, improve quality of life 4
• Salt restriction and diuretics to prevent flare-ups 7, 8
• Vestibular suppressants (anticholinergics, benzodiazepines) during acute attacks only 7
• Once acute fluctuating symptoms controlled, vestibular rehabilitation therapy demonstrates significant improvement in balance function 9, 10
• Non-ablative procedures preferred for patients with usable hearing 4

Recurrence Management

BPPV has high recurrence rates:

• 10-18% at 1 year 1, 2
• 30-50% at 5 years 1, 2
• Overall estimated 15% per year 1, 2

Each recurrence should be treated with repeat CRP, which maintains same high success rates of 90-98% 2

Counsel patients regarding:

• Impact on safety and fall risk 1
• Potential for recurrence 1
• Importance of follow-up 1
• Home safety assessment and activity restrictions if high fall risk 2

Common Pitfalls to Avoid

• Relying on medications instead of repositioning maneuvers—this is the most common error 2, 3
• Failing to reassess patients after initial treatment 2, 3
• Missing canal conversions or multiple canal involvement 2, 3
• Not moving patient quickly enough during maneuvers reduces effectiveness 2
• Ordering unnecessary imaging or vestibular testing in straightforward BPPV cases 1, 2
• Recommending postprocedural restrictions after CRP—strong evidence shows no benefit 1, 2