What is the best course of action for a patient with persistent dizziness since June?

Evaluation and Management of Persistent Dizziness Since June

For a patient with dizziness persisting since June, perform the Dix-Hallpike maneuver to diagnose benign paroxysmal positional vertigo (BPPV), and if positive, treat immediately with the Epley maneuver (canalith repositioning procedure), which achieves 70-80% resolution after a single treatment. 1

Initial Diagnostic Approach

Classify the dizziness by timing and triggers, not descriptive terms:

• Triggered episodic (brief episodes <1 minute with position changes): Most likely BPPV 2
• Spontaneous episodic (minutes to hours without triggers): Consider Ménière's disease, vestibular migraine, or vertebrobasilar TIA 2
• Acute vestibular syndrome (continuous days to weeks): Vestibular neuritis, labyrinthitis, or posterior circulation stroke 2
• Chronic vestibular syndrome (weeks to months): Anxiety disorders, medication side effects, or posterior fossa masses 2

Given the June onset (several months duration), this represents chronic vestibular syndrome requiring systematic evaluation. 2

Essential Physical Examination

Perform the Dix-Hallpike maneuver to assess for posterior canal BPPV by bringing the patient from upright to supine with head turned 45° to one side and neck extended 20°. 3

Positive BPPV findings include:

• 5-20 second latency before nystagmus onset 1
• Torsional upbeating nystagmus toward the affected ear 1
• Symptoms resolving within 60 seconds 1
• Fatigability with repeated testing 2

Perform supine roll test to assess for lateral semicircular canal BPPV. 3

Red flags requiring immediate neuroimaging (MRI brain without contrast):

• Severe postural instability with falling 2
• New-onset severe headache with vertigo 2
• Any focal neurological deficits (dysarthria, dysmetria, dysphagia, sensory/motor deficits, diplopia) 2
• Downbeating nystagmus on Dix-Hallpike without torsional component 2
• Pure vertical nystagmus without torsional component 2
• Direction-changing nystagmus without head position changes 2
• Nystagmus not suppressed by visual fixation 2
• Sudden hearing loss 1
• Inability to stand or walk independently 1

Treatment Algorithm

If BPPV is confirmed:

1. Perform Epley maneuver (canalith repositioning procedure) immediately - achieves 70-80% resolution after single treatment and 90-98% after repeat maneuvers. 1 This is 2.5-3 times more effective than observation alone. 3

2. Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment - success rate only 30.8% compared to 78.6-93.3% for repositioning maneuvers. 1 These medications interfere with central compensation and should only be used short-term for severe symptoms. 3

3. Do NOT recommend postprocedural postural restrictions after canalith repositioning. 3

4. Offer vestibular rehabilitation (self-administered or with clinician) as adjunctive treatment. 3

If BPPV is ruled out or atypical features present:

• Assess for modifying factors: impaired mobility/balance, CNS disorders, lack of home support, increased fall risk. 3

• Evaluate for Ménière's disease if patient has episodic vertigo with fluctuating hearing loss, tinnitus, and aural fullness. 2

• Consider vestibular migraine if patient has migraine history with motion intolerance, photophobia, or visual auras during vertigo episodes, but stable (not fluctuating) hearing. 2

• Evaluate medication list for vestibulotoxic agents (aminoglycosides, anticonvulsants, antihypertensives, cardiovascular medications). 2

Imaging Decisions

Do NOT obtain imaging if:

• Patient meets diagnostic criteria for BPPV with typical Dix-Hallpike findings 3
• No additional neurological symptoms inconsistent with BPPV 3
• Normal neurologic examination 3

Obtain MRI brain without IV contrast if:

• Red flags present (listed above) 3, 1
• High vascular risk patients even with normal neurologic exam 3
• Atypical presentation or equivocal Dix-Hallpike findings 2
• Failure to respond to appropriate peripheral vertigo treatments 2

Note: CT imaging has low diagnostic yield (approximately 4%) for isolated dizziness and should not be relied upon. 3

Do NOT obtain vestibular testing in patients meeting diagnostic criteria for BPPV without additional vestibular signs/symptoms. 3

Follow-Up and Patient Education

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

If symptoms persist:

• Re-evaluate for unresolved BPPV (repeat Dix-Hallpike) 3
• Consider underlying peripheral vestibular or CNS disorders 3
• Evaluate for concurrent diagnoses (BPPV can coexist with Ménière's disease or vestibular neuritis) 2

Counsel patients about:

• Risk of BPPV recurrence: 10-18% at 1 year, up to 36% long-term 1
• Fall risk during symptomatic periods 1
• Importance of returning promptly if symptoms recur 1
• Safety precautions at home during watchful waiting 3

Common Pitfalls to Avoid

• Prescribing meclizine as first-line treatment instead of performing Epley maneuver - this delays effective treatment and has much lower success rates. 1, 4

• Ordering unnecessary imaging in straightforward BPPV cases - this increases costs and delays treatment. 3

• Missing central causes by not performing thorough neurologic examination or recognizing red flags - approximately 25% of acute vestibular syndrome cases have cerebrovascular disease. 2

• Overlooking medication-induced dizziness - review all medications for vestibulotoxic effects. 2

• Failing to distinguish fluctuating hearing loss (Ménière's disease) from stable hearing loss (vestibular migraine). 2