What is the best course of treatment for a patient presenting with vestibular disturbance?

Treatment of Vestibular Disturbance

For patients presenting with vestibular disturbance, immediately perform the Dix-Hallpike maneuver to diagnose benign paroxysmal positional vertigo (BPPV), and if positive, treat with the Epley maneuver (canalith repositioning procedure) at the same visit—this achieves 80-90% success rates and is the definitive first-line treatment without need for medications or imaging. 1

Diagnostic Algorithm by Symptom Timing

Step 1: Classify the Vestibular Disturbance

• Episodic positional vertigo (seconds to minutes, triggered by head position changes): Perform Dix-Hallpike test for posterior canal BPPV (85-95% of cases) and supine roll test for lateral canal BPPV (10-15% of cases) 1, 2
• Acute continuous vertigo (lasting >24 hours with nausea/vomiting): This represents acute vestibular syndrome requiring differentiation between peripheral (vestibular neuritis) versus central (stroke) causes using HINTS Plus examination 3, 4
• Recurrent episodic vertigo (minutes to hours, spontaneous): Consider Ménière's disease (with hearing loss, tinnitus, aural fullness) or vestibular migraine (with headache, photophobia, phonophobia) 5

Step 2: Identify Red Flags for Central Causes

Do NOT assume peripheral vestibular disorder if any of these are present: 5, 6

• Direction-changing nystagmus without head position changes
• Downbeating nystagmus on Dix-Hallpike
• Severe headache preceding vertigo onset
• Dysarthria, dysmetria, or dysphagia
• Sensory or motor deficits
• Horner's syndrome
• Failure of repositioning maneuvers to reproduce or relieve symptoms

If red flags present: Obtain MRI brain with attention to posterior fossa immediately, as 10% of cerebellar strokes present similarly to peripheral vestibular processes 6

Treatment by Specific Diagnosis

BPPV (Most Common—85-95% Posterior Canal)

Posterior Canal BPPV:

• Perform Epley maneuver immediately: Patient sits upright with head turned 45° toward affected ear → rapidly lay back to supine head-hanging 20° position for 20-30 seconds → turn head 90° toward unaffected side for 20-30 seconds → roll patient onto side with nose pointing down 45° for 20-30 seconds → return to sitting 1
• Success rate: 80-90% after 1-3 treatments; 90-98% with repeat maneuvers if needed 1, 2
• Alternative: Semont (Liberatory) maneuver with 94.2% resolution at 6 months 1

Lateral Canal BPPV:

• Geotropic variant: Gufoni maneuver (93% success) or Barbecue Roll maneuver (75-90% success) 1, 2
• Apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side) 1

Critical Post-Treatment Instructions:

• Patients can resume normal activities immediately—postprocedural restrictions provide NO benefit and may cause unnecessary complications 1, 2
• Reassess within 1 month to confirm symptom resolution 1, 2

Acute Vestibular Syndrome (Vestibular Neuritis vs. Stroke)

• Vestibular neuritis (peripheral): Vestibular rehabilitation therapy is the primary treatment; vestibular suppressants (meclizine 25-100 mg daily) may be used SHORT-TERM (2-3 days maximum) only for severe nausea/vomiting 7, 3
• Stroke (central): Immediate neurology consultation and stroke protocol 3, 4

Ménière's Disease

• Acute attacks: Salt restriction (<1500-2000 mg/day), diuretics, and short-term vestibular suppressants during attacks only 5, 2
• Long-term management: Dietary/lifestyle modifications, vestibular rehabilitation therapy 5

Vestibular Migraine

• First-line: Lifestyle modifications (dietary triggers, regular sleep, hydration), preventive medications (beta-blockers, topiramate) 6
• Acute attacks: Triptans for concurrent headache, short-term antiemetics 6

Medication Management: Critical Pitfalls

DO NOT routinely prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV or as primary treatment for any vestibular disorder: 1, 2

• No evidence of effectiveness as definitive treatment 1
• Cause significant adverse effects: drowsiness, cognitive deficits, increased fall risk (especially elderly) 1, 7
• Interfere with central compensation mechanisms in peripheral vestibular conditions 1
• Decrease diagnostic sensitivity during Dix-Hallpike maneuvers 1

Limited role for medications: Only consider for short-term (2-3 days) management of severe nausea/vomiting in severely symptomatic patients 1, 7

Vestibular Rehabilitation Therapy

• Offer as adjunctive therapy (not substitute for repositioning maneuvers) particularly for: 1, 2
  • Residual dizziness after successful repositioning
  • Postural instability or heightened fall risk
  • Recurrent BPPV (reduces recurrence by ~50%)
  • Vestibular neuritis recovery

Treatment Failures: Reassessment Protocol

If symptoms persist after 2-3 properly performed Epley maneuvers: 1, 6

1. Repeat diagnostic testing: Confirm persistent BPPV with Dix-Hallpike or supine roll test
2. Check for canal conversion: Occurs in 6-7% of cases (posterior → lateral or vice versa)
3. Evaluate for multiple canal involvement: Rare but possible
4. Rule out coexisting vestibular pathology: 25-50% of recurrent BPPV patients have associated vestibular disorders (Ménière's, vestibular neuritis)
5. Consider CNS disorders: Especially if atypical features present
6. Obtain comprehensive vestibular function testing and neuroimaging if symptoms persist after comprehensive evaluation 6

Special Populations Requiring Modified Approach

Assess ALL patients before treatment for contraindications: 1

• Severe cervical stenosis or radiculopathy
• Severe rheumatoid arthritis or ankylosing spondylitis
• Morbid obesity
• Known cerebrovascular disease
• Severe kyphoscoliosis or limited cervical range of motion

For patients with contraindications: Consider Brandt-Daroff exercises (performed three times daily for 2 weeks) or refer to specialized vestibular physical therapy, though these are significantly less effective than repositioning maneuvers (24% vs. 71-74% success at 1 week) 1

Fall Risk Assessment

BPPV increases fall risk 12-fold, particularly in elderly patients: 1

• 9% of patients referred to geriatric clinics have undiagnosed BPPV
• Three-quarters of elderly BPPV patients have fallen within previous 3 months
• Immediately counsel regarding home safety assessment, activity restrictions, and need for supervision

Self-Treatment Options

• Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment—64% improvement rate compared to 23% with Brandt-Daroff exercises 1

Imaging and Testing: When NOT to Order

Do NOT obtain radiographic imaging or vestibular testing in patients who meet clinical criteria for BPPV in the absence of additional signs or symptoms inconsistent with BPPV 1, 6

Only order imaging when: Red flags present, atypical neurological signs, or failure to respond to appropriate treatment after comprehensive reassessment 5, 6