What is the best course of action for a female patient experiencing vertigo (dizziness) upon closing her eyes, accompanied by slight neck stiffness and bloating?

Evaluation and Management of Vertigo with Eye Closure, Neck Stiffness, and Bloating

This patient requires immediate diagnostic evaluation with the Dix-Hallpike maneuver to confirm benign paroxysmal positional vertigo (BPPV), followed by canalith repositioning procedure (Epley maneuver) if positive—the neck stiffness and bloating are likely unrelated symptoms that should not delay BPPV treatment. 1

Initial Diagnostic Approach

The vertigo triggered by closing eyes suggests a positional component that is highly characteristic of BPPV, the most common cause of peripheral vertigo accounting for 42% of cases 2. The key diagnostic test is the Dix-Hallpike maneuver, which should be performed immediately 1.

Performing the Dix-Hallpike Maneuver

• Position the patient upright with head turned 45° to one side 1
• Rapidly bring the patient to supine position with head extended 20° beyond the table edge 1
• Observe for characteristic findings:
  • Latency period of 5-20 seconds before symptoms begin 1, 3
  • Torsional, upbeating nystagmus toward the affected ear 1
  • Vertigo and nystagmus that increase then resolve within 60 seconds 1
• If the first side is negative, repeat with the opposite ear down before concluding the test is negative 1

If Dix-Hallpike is Negative

Perform the supine roll test to assess for lateral (horizontal) semicircular canal BPPV, which accounts for 10-15% of BPPV cases 1:

• Position patient supine with head neutral 1
• Rapidly rotate head 90° to one side, observing for horizontal nystagmus 1
• Return to neutral, then rapidly rotate 90° to opposite side 1
• Look for geotropic (most common) or apogeotropic nystagmus patterns 1

Immediate Treatment Protocol

For Posterior Canal BPPV (Most Likely)

Perform the Epley maneuver immediately upon diagnosis with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers 4:

1. Patient sits upright, head turned 45° toward affected ear 4
2. Rapidly lay back to supine head-hanging 20° position, hold 20-30 seconds 4
3. Turn head 90° toward unaffected side, hold 20-30 seconds 4
4. Roll patient onto side with nose pointed downward 45°, hold 20-30 seconds 4
5. Return to upright sitting position 4

For Lateral Canal BPPV

• Geotropic variant: Perform Barbecue Roll (Lempert) maneuver with 50-100% success rate 4
• Apogeotropic variant: Perform Modified Gufoni maneuver 4

Critical Management Points

What NOT to Do

Do not prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV 4:

• No evidence of effectiveness as definitive treatment 4
• Cause drowsiness, cognitive deficits, and increased fall risk 4
• Interfere with central compensation mechanisms 4
• May only be considered for severe nausea/vomiting in severely symptomatic patients 4

Do not order imaging or vestibular testing for typical BPPV with positive Dix-Hallpike and no neurological red flags 3, 4:

• CT has <1% diagnostic yield for isolated dizziness 3
• Imaging delays appropriate treatment 3

Post-Treatment Instructions

Patients can resume normal activities immediately after canalith repositioning—postprocedural restrictions provide no benefit and may cause unnecessary complications 4.

Addressing the Associated Symptoms

Neck Stiffness

The slight neck stiffness is likely unrelated to the vertigo and should not delay BPPV treatment 1. However, assess for contraindications to repositioning maneuvers 1:

• Severe cervical stenosis
• Severe rheumatoid arthritis or cervical radiculopathies
• Known cerebrovascular disease

If contraindications exist, consider Brandt-Daroff exercises as an alternative, though less effective (24% vs 71-74% success rate at 1 week) 4.

Bloating

The bloating is not a typical symptom of vestibular disorders and represents a separate gastrointestinal complaint that should be addressed independently after managing the acute vertigo.

Red Flags Requiring Urgent Neuroimaging

Immediately obtain MRI brain without contrast if any of the following are present 3, 2:

• Focal neurological deficits (dysarthria, dysmetria, dysphagia, motor/sensory deficits) 2
• New severe headache with vertigo 3
• Pure vertical nystagmus without torsional component 2
• Direction-changing nystagmus without head position changes 2
• Nystagmus not suppressed by visual fixation 2
• Severe postural instability with falling 2
• Failure to respond to appropriate repositioning procedures 2

Follow-Up Protocol

Reassess within 1 month to confirm symptom resolution 1, 4:

• If symptoms persist, repeat Dix-Hallpike test to confirm persistent BPPV 1
• Repeat repositioning maneuvers achieve 90-98% success rates 1, 4
• Consider canal conversion (occurs in 6-7% of cases) 4
• Evaluate for multiple canal involvement or coexisting vestibular pathology 1

Common Pitfalls to Avoid

• Assuming normal neurologic exam excludes stroke: 75-80% of patients with posterior circulation infarct have no focal neurologic deficits 3
• Relying on patient's description of "spinning": Focus on timing and triggers instead 3
• Failing to perform positional testing: The Dix-Hallpike maneuver is essential and cannot be replaced by history alone 1
• Prescribing medications instead of performing repositioning: Canalith repositioning is 12 times more effective than a week of exercises 4