What is the next step for a patient with persistent dizziness when changing positions, who has not improved with meclizine (antihistamine) treatment for 1 week, and should they be referred to a neurologist or an ear, nose, and throat (ENT) specialist?

Management of Persistent Positional Dizziness After Failed Meclizine Trial

Stop meclizine immediately and perform a Dix-Hallpike maneuver to diagnose BPPV, then treat with the Epley maneuver—refer to ENT (otolaryngology), not neurology, for persistent symptoms after 2-3 repositioning attempts or if red flag features are present. 1

Why Meclizine Failed

• Meclizine is a vestibular suppressant that only masks symptoms without addressing the underlying cause and should not be used as definitive primary treatment for vertigo 1
• Vestibular suppressants have no evidence supporting effectiveness as primary treatment and may interfere with the brain's natural compensation mechanisms 1
• The Epley maneuver achieves 78.6-93.3% symptom improvement compared to only 30.8% with medication alone 1
• Meclizine should be discontinued beyond acute symptom management (typically no more than a few days), as prolonged use interferes with vestibular compensation and delays recovery 1

Immediate Next Steps

Perform diagnostic maneuvers now:

• Execute the Dix-Hallpike maneuver: bring the patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus that confirms posterior canal BPPV 2
• Perform supine roll testing to identify direction-changing horizontal nystagmus indicating lateral canal BPPV 2
• If either test is positive, immediately perform the Epley maneuver (for posterior canal) or appropriate repositioning maneuver (for lateral canal) 1

Treatment Algorithm

If BPPV is confirmed:

• Perform particle repositioning maneuvers (Epley or Semont maneuver), which achieve 90-98% success rates with repeated sessions 2
• Repeat the Epley maneuver if symptoms persist after the first attempt, as success rates reach 90-98% with additional repositioning attempts 1
• Reassess within 1 month to confirm symptom resolution or identify treatment failures 1

If symptoms persist after 2-3 proper repositioning attempts:

• This constitutes treatment failure and raises concern for central pathology rather than BPPV 2
• Approximately 1.1-3% of presumed BPPV cases have underlying CNS disorders 1
• Refer to ENT (otolaryngology) for comprehensive vestibular evaluation, as the American Academy of Otolaryngology-Head and Neck Surgery guidelines specifically address evaluation of treatment failures 3, 2

Red Flags Requiring Immediate Evaluation

Watch for these concerning features that suggest central causes:

• Critical nystagmus patterns: downbeating nystagmus on Dix-Hallpike, direction-changing nystagmus without head position changes, gaze-evoked nystagmus, or baseline nystagmus without provocative maneuvers 2
• Associated neurologic findings: dysarthria, dysmetria, dysphagia, sensory/motor deficits, or Horner's syndrome 2
• New severe headache different from typical patterns, focal neurological deficits, sudden hearing loss, or inability to stand or walk 4
• Approximately 10% of cerebellar strokes present similarly to peripheral vestibular disorders 2

ENT vs. Neurology Referral Decision

Refer to ENT (otolaryngology) for:

• Persistent positional dizziness after failed repositioning attempts (most likely scenario) 3, 2
• Evaluation of peripheral vestibular disorders including BPPV, Ménière's disease, vestibular neuritis 3
• Comprehensive vestibular testing including audiogram, video/electronystagmogram, and electrocochleography 3
• The American Academy of Otolaryngology-Head and Neck Surgery guidelines specifically recommend ENT evaluation for treatment failures 3

Refer to neurology only if:

• Red flag neurological symptoms are present (dysarthria, focal deficits, abnormal HINTS examination) 4, 2
• MRI reveals central pathology 4
• Vestibular migraine is suspected (dizziness with headache, photophobia, phonophobia, temple/neck tension) 4

Additional Management Options

Vestibular rehabilitation therapy:

• Initiate for patients who fail initial repositioning attempts, have additional vestibular impairments, or are not candidates for repositioning maneuvers 1
• Vestibular rehabilitation promotes central compensation and provides long-term recovery superior to medication 1

Lifestyle modifications if Ménière's disease is considered:

• Limit sodium intake to 1500-2300 mg daily 1
• Avoid excessive caffeine, alcohol, and nicotine 1
• Maintain adequate hydration, regular sleep patterns, and stress management 1

Common Pitfalls to Avoid

• Do not continue vestibular suppressants beyond a few days, as this interferes with vestibular compensation 1
• Do not assume BPPV without performing diagnostic maneuvers—lack of response to meclizine suggests either incorrect diagnosis or that BPPV requires mechanical treatment, not medication 1
• Do not miss central causes that mimic BPPV—failure to respond to proper repositioning maneuvers should prompt consideration of CNS pathology 2, 1
• Do not order CT brain for persistent dizziness, as it has only 20-40% sensitivity for detecting posterior circulation pathology and misses most causes of persistent dizziness 4

Follow-Up Protocol

• Schedule reassessment within 1 month to document complete symptom resolution or identify persistent symptoms requiring alternative diagnosis 1
• Treatment failure is defined as lack of complete symptom resolution and requires repeat Dix-Hallpike testing and consideration of alternative diagnoses 1
• If symptoms persist despite proper treatment, ENT referral is appropriate for comprehensive vestibular evaluation and consideration of MRI brain without contrast 3, 4