What are the appropriate management and treatment strategies for a patient experiencing dizziness, possibly due to conditions like benign paroxysmal positional vertigo (BPPV) or other underlying causes?

Management of Dizziness

For a patient presenting with dizziness, immediately classify the symptom by timing and triggers rather than descriptive quality, perform a Dix-Hallpike maneuver if episodes are triggered by head position changes, and treat confirmed BPPV with canalith repositioning procedures (Epley maneuver) rather than medications. 1

Initial Diagnostic Approach: Focus on Timing and Triggers

The key to diagnosing dizziness is categorizing it into one of four vestibular syndromes based on timing and triggers, not on patient descriptors like "spinning" or "lightheadedness" 1:

• Triggered Episodic Vestibular Syndrome (episodes <1 minute triggered by head position changes): Most commonly BPPV, postural hypotension, or perilymphatic fistula 1, 2
• Spontaneous Episodic Vestibular Syndrome (episodes lasting minutes to hours without triggers): Vestibular migraine, Ménière's disease, or vertebrobasilar TIA 1, 2
• Acute Vestibular Syndrome (continuous dizziness lasting days to weeks): Vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 2
• Chronic Vestibular Syndrome (dizziness lasting weeks to months): Anxiety disorders, medication side effects, or posterior fossa masses 1, 2

Critical Physical Examination Maneuvers

Dix-Hallpike Maneuver (for triggered episodic dizziness)

Perform this immediately when episodes are triggered by head position changes 1:

• Positive for BPPV: Torsional and upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, fatigues with repeat testing, resolves within 60 seconds 3
• Red flags for central pathology: Immediate onset without latency, purely vertical nystagmus without torsional component, persistent nystagmus that doesn't fatigue, or downbeating nystagmus 3, 4

HINTS Examination (for acute vestibular syndrome)

Use this to distinguish peripheral from central causes when continuous vertigo is present 3, 5:

• Head impulse test: Abnormal (corrective saccade) suggests peripheral; normal suggests central 3
• Nystagmus assessment: Unidirectional horizontal-torsional suggests peripheral; direction-changing or purely vertical suggests central 3
• Test of skew: Vertical misalignment suggests central pathology 3

Differential Diagnosis by Common Presentations

BPPV (Most Common Cause - 42% of vertigo cases)

• Brief episodes (<1 minute) triggered by rolling over in bed, lying down, or looking up 1, 2
• Positive Dix-Hallpike with characteristic nystagmus 1, 3
• No hearing loss, tinnitus, or neurological symptoms 1, 2

Ménière's Disease

• Episodes lasting hours with fluctuating hearing loss, tinnitus, and aural fullness 1, 2
• Spontaneous attacks not triggered by position 1, 2
• Progressive hearing loss over time distinguishes it from vestibular migraine 3

Vestibular Migraine

• Episodes lasting minutes to >24 hours with photophobia and motion intolerance 2, 3
• Stable or absent hearing loss (not fluctuating like Ménière's) 3
• Current or past migraine history, family history of migraine 3

Vestibular Neuritis

• Sudden onset continuous vertigo lasting days with severe nausea and vomiting 1, 2
• No hearing loss (distinguishes from labyrinthitis) 2
• Abnormal head impulse test 3

When to Obtain Imaging (Red Flags for Central Pathology)

Do NOT obtain imaging for typical BPPV with characteristic Dix-Hallpike findings 1, 3. Obtain urgent neuroimaging if any of these are present 3, 4:

• Severe postural instability with falling 3
• New-onset severe headache with vertigo 3
• Any additional neurological symptoms (dysarthria, diplopia, limb weakness, sensory deficits) 3
• Downbeating nystagmus without torsional component 3, 4
• Direction-changing nystagmus without head position changes 3, 4
• Baseline nystagmus without provocative maneuvers 3, 4
• Failure to respond to appropriate peripheral vertigo treatments 3, 4

Treatment Strategies

BPPV: Canalith Repositioning Procedure (First-Line)

Perform the Epley maneuver immediately if Dix-Hallpike is positive 1, 3, 4:

• Success rate: 80-93% after 1-3 treatments 4
• Do NOT prescribe post-procedural positional restrictions (no evidence of benefit) 1
• Do NOT prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) as primary treatment—they interfere with central compensation and have only 30.8% efficacy vs 78.6-93.3% for repositioning 1, 4, 6
• Reassess within 1 month; if persistent, repeat repositioning maneuvers (success reaches 90-98% with additional treatments) 1

Vestibular Suppressant Medications: Limited Role

Vestibular suppressants should NOT be routinely used for BPPV 1. Consider meclizine 25-100 mg daily only for 4, 6:

• Severe nausea/vomiting during the repositioning maneuver itself 4
• Acute attacks of Ménière's disease (short-term use only, 3-5 days maximum) 4
• Patients who refuse repositioning procedures 4

Contraindications and warnings 6:

• Avoid in patients with asthma, glaucoma, or prostate enlargement 6
• Causes drowsiness, cognitive deficits, increased fall risk (especially in elderly) 4, 6
• Warn patients against driving or operating machinery 6
• Avoid concurrent alcohol use 6

Ménière's Disease

• First-line: Dietary sodium restriction (1500-2300 mg daily) plus diuretics 4
• Limit alcohol and caffeine intake 4
• Short-term vestibular suppressants (meclizine 25-100 mg daily) for acute attacks only 4
• Consider betahistine for inner ear vasodilation 4
• Intratympanic dexamethasone or gentamicin for refractory cases 7

Vestibular Neuritis

• Steroids (if initiated within 72 hours of symptom onset) 7
• Vestibular rehabilitation (accelerates recovery) 4, 5
• Short-term vestibular suppressants for severe symptoms only (3-5 days maximum) 4

Vestibular Rehabilitation

Indicated for 4:

• Persistent dizziness from any vestibular cause after initial treatment 4
• Chronic imbalance or incomplete recovery 4
• Can be self-administered or therapist-directed 1, 4

Patient Counseling and Follow-Up

Counsel all patients with BPPV on 1:

• Fall risk: BPPV significantly increases fall risk, especially in elderly; assess home safety and consider activity restrictions until resolved 1
• Recurrence rates: 10-18% at 1 year, up to 36% long-term; higher after trauma 1
• When to return: If symptoms persist after 1 month, recur after resolution, or if atypical symptoms develop (hearing loss, gait disturbance, non-positional vertigo) 1
• Reassurance: BPPV is benign and not a stroke; simple repositioning maneuvers are highly effective 1

Reassess within 1 month to document resolution or identify treatment failures requiring reevaluation for persistent BPPV, coexisting vestibular conditions, or serious CNS disorders 1, 4

Common Pitfalls to Avoid

• Misdiagnosing central causes as peripheral: Approximately 10% of cerebellar strokes mimic peripheral vestibular disorders; 25% of acute vestibular syndrome cases have cerebrovascular disease 3
• Prescribing vestibular suppressants for BPPV: These medications are ineffective as primary treatment and delay recovery 1, 4
• Failing to perform Dix-Hallpike: This is the definitive diagnostic test for BPPV and must be performed when episodes are triggered by position changes 1, 3
• Ordering unnecessary imaging: Do not obtain imaging for typical BPPV without red flags 1, 3
• Overlooking vestibular migraine: This is extremely common (lifetime prevalence 3.2%) but under-recognized, especially in young women with both migraine and vertigo 3
• Missing medication-induced dizziness: Review all medications, especially antihypertensives, anticonvulsants, and cardiovascular drugs 2, 4