What are the treatment options for a patient experiencing vertigo at night, possibly with a history of Benign Paroxysmal Positional Vertigo (BPPV)?

Treatment of Nighttime Vertigo in BPPV

For a patient experiencing vertigo at night with suspected BPPV, perform the Dix-Hallpike maneuver at the bedside to confirm the diagnosis, then immediately treat with the Epley maneuver (canalith repositioning procedure) in the office—this achieves 80% success rates and is the definitive treatment, while avoiding vestibular suppressant medications like meclizine which are ineffective for BPPV. 1, 2

Diagnostic Approach

Confirm the diagnosis with positional testing:

• Perform the Dix-Hallpike maneuver bilaterally to identify which ear is affected and observe for characteristic torsional, upbeating nystagmus with a latency period of 5-20 seconds (occasionally up to 1 minute) that resolves within 60 seconds. 1, 2

• If the Dix-Hallpike is negative but the history strongly suggests positional vertigo (especially symptoms triggered by rolling over in bed at night), perform the supine roll test to evaluate for horizontal canal BPPV. 2, 3

• The classic history includes brief episodes (10-60 seconds) of rotational vertigo triggered by head position changes—commonly rolling over in bed, looking upward, or bending forward—with patients often modifying movements to avoid triggering episodes. 1, 4, 5

Immediate Treatment

Perform canalith repositioning in the office today:

• The Epley maneuver (for posterior canal BPPV) or appropriate variant repositioning procedure should be performed immediately upon diagnosis, as this achieves 80% success rates after 1-3 in-office treatments. 1, 2, 3

• Repeated testing and treatment within the same session is safe and effective—91% of posterior canal BPPV cases resolve with 2 maneuvers or less. 6

• Warn the patient that the maneuver will provoke intense vertigo that subsides within 60 seconds, and counsel them about the procedure beforehand. 1

Do NOT prescribe vestibular suppressants as primary treatment:

• Medications like meclizine, antihistamines, or benzodiazepines are ineffective for BPPV and interfere with central vestibular compensation. 1, 2, 3

• While meclizine is FDA-approved for "vertigo associated with diseases affecting the vestibular system," 7 the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against these medications for BPPV because they decrease diagnostic sensitivity during testing and provide no benefit over repositioning procedures. 1, 2

Critical Safety Measures for Nighttime Symptoms

Provide explicit fall precautions, especially given nighttime occurrence:

• Elderly patients with BPPV have a 12-fold increased risk of falls, and 9% of geriatric patients with undiagnosed BPPV had fallen within 3 months prior to diagnosis. 1

• Specific nighttime precautions include: using nightlights, avoiding sudden head movements when getting up, sitting at the edge of the bed before standing, and considering bed rails or assistance for nighttime bathroom trips. 2

• Additional safety measures: use assistive devices if needed, ensure adequate lighting throughout the home, remove tripping hazards, and consider supervision until symptoms resolve. 2

• Assess fall risk using screening questions: (1) Have you fallen in the past year? (2) Do you feel unsteady when standing or walking? (3) Do you worry about falling? 1

Follow-Up and Monitoring

Reassess within 1 month to confirm resolution:

• Schedule follow-up within 1 month (or sooner if symptoms persist) to confirm symptom resolution, as 20-80% of cases resolve spontaneously by 1 month, but treatment failures require identification. 1, 2

• Persistence of symptoms after appropriate repositioning may indicate: (1) an initially erroneous diagnosis (1.1-3% of presumed BPPV cases are actually CNS lesions), (2) need for additional repositioning sessions, (3) bilateral or multiple canal involvement, or (4) concurrent vestibular disorders. 1, 3

• Posttraumatic BPPV (if there's a history of head trauma) requires repeated repositioning in up to 67% of cases compared to 14% for non-traumatic forms. 1

Counsel about recurrence:

• BPPV recurs in 15-50% of cases, and patients should return immediately for repeat repositioning if positional dizziness recurs. 2, 3

• The first episode is typically the most severe, with subsequent episodes being less intense. 4

Red Flags Requiring Further Evaluation

Watch for atypical features suggesting alternative diagnoses:

• Constant severe dizziness unaffected by position, hearing loss, neurological symptoms (dysarthria, dysmetria, dysphagia, sensory/motor deficits), persistent nausea/vomiting, or non-positional vertigo all suggest underlying vestibular or CNS disorders requiring additional workup. 3, 4

• Failure to respond to appropriate repositioning after 2-3 attempts warrants reassessment for alternative diagnoses. 3, 4