What is the appropriate management for a patient presenting with severe, pulsating, throbbing, and stabbing pain behind the right eye, rated 10/10, accompanied by nausea, vomiting, and vertigo, particularly when exacerbated by the Dix-Hallpike (Dix-Hallpike maneuver) maneuver?

This Patient Does NOT Have BPPV—Immediate Neuroimaging and Neurology Consultation Are Required

This clinical presentation is highly concerning for a central nervous system disorder, not benign paroxysmal positional vertigo (BPPV), and requires urgent evaluation with MRI brain imaging and neurology consultation. The severe unilateral pain (10/10, pulsating, throbbing, stabbing behind the right eye), combined with nausea, vomiting, and vertigo that worsens with head turning, suggests a vascular or structural CNS pathology rather than a benign peripheral vestibular disorder.

Why This Is NOT BPPV

The clinical features are fundamentally incompatible with BPPV:

• Severe pain is not a feature of BPPV. Patients with posterior canal BPPV typically describe rotational vertigo when changing head position, but do NOT report severe pain behind the eye 1, 2. True BPPV patients may report lightheadedness, dizziness, or feeling "off balance," but not stabbing, pulsating pain rated 10/10 2.

• Pain with head turning during the Dix-Hallpike maneuver is a red flag. The American Academy of Otolaryngology-Head and Neck Surgery explicitly warns that clinicians should exercise caution in patients with significant vascular disease, cervical stenosis, or severe rheumatoid arthritis when performing the Dix-Hallpike maneuver 1, 2. Severe pain provoked by head turning suggests cervical pathology, vertebrobasilar insufficiency, or other serious conditions 3.

• The symptom complex suggests posterior circulation ischemia or other CNS pathology. The combination of severe unilateral retro-orbital pain, vertigo, nausea, and vomiting with positional worsening raises concern for vertebrobasilar insufficiency, posterior circulation stroke, cerebellar hemorrhage, or other central causes 4, 5.

Immediate Management Algorithm

Step 1: Stop attempting positional testing immediately

• Do not repeat the Dix-Hallpike maneuver or any other positional testing 1, 2
• The severe pain with head turning is a contraindication to further manipulation 3

Step 2: Perform focused neurological examination

• Assess for cranial nerve deficits, particularly those suggesting posterior fossa pathology 4
• Evaluate for spontaneous nystagmus (direction-changing or vertical nystagmus suggests central pathology) 4
• Test gait if safe to do so—severe gait unsteadiness suggests central cause 4
• Check for signs of cerebellar dysfunction (dysmetria, dysdiadochokinesia) 5

Step 3: Obtain urgent neuroimaging

• MRI brain with diffusion-weighted imaging is the preferred test for patients with acute dizziness/vertigo and atypical features 2, 4
• The American College of Radiology recommends MRI as the preferred imaging modality when the Dix-Hallpike test produces atypical findings or when there are concerning neurologic symptoms 2
• CT brain is NOT adequate—it misses acute posterior circulation strokes and has poor sensitivity for cerebellar pathology 4

Step 4: Consider vascular imaging

• CT angiography or MRI angiography of the head and neck should be obtained if there is concern for vertebrobasilar insufficiency or dissection 4
• The severe pain with head turning raises particular concern for vertebral artery dissection 3

Critical Red Flags Present in This Case

Multiple features indicate this is NOT a benign peripheral vestibular disorder:

• Severe pain (10/10) is never a feature of BPPV 1, 2
• Unilateral retro-orbital pain suggests vascular or structural pathology 5
• Pain provoked by head turning during examination suggests cervical vascular or structural pathology 1, 3
• The severity of symptoms (nausea, vomiting, inability to tolerate positional testing) is disproportionate to typical BPPV 1

What NOT to Do

Do not treat this as BPPV:

• Do not perform canalith repositioning procedures (Epley maneuver) 1, 6
• Do not prescribe vestibular suppressants and discharge the patient 6
• Do not rely on CT brain alone—it has inadequate sensitivity for posterior circulation pathology 4
• Do not assume a negative CT rules out serious pathology 4

Do not continue positional testing:

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that the Dix-Hallpike maneuver should be avoided in patients with significant vascular disease, and clinicians should be careful to consider the risk of stroke or vascular injury 1
• Although there are no documented reports of vertebrobasilar insufficiency provoked by the Dix-Hallpike maneuver, the severe pain with head turning in this patient warrants extreme caution 1, 3

Differential Diagnosis to Consider

Central causes that can mimic BPPV but present with severe pain:

• Vertebrobasilar insufficiency or posterior circulation stroke (vertigo + severe headache + nausea/vomiting) 4, 5
• Vertebral artery dissection (severe neck/head pain + vertigo + provoked by head turning) 3
• Cerebellar hemorrhage or infarction (severe headache + vertigo + nausea/vomiting + inability to tolerate head movement) 5
• Posterior fossa mass lesion (progressive symptoms + severe headache + vertigo) 5

Other considerations:

• Complicated migraine with vertigo (severe unilateral headache + vertigo + nausea/vomiting), though the pain with head turning is atypical 7
• Cervical pathology with vertebral artery compromise (pain with head turning + vertigo) 3

Common Pitfalls to Avoid

The most dangerous pitfall is assuming all positional vertigo is BPPV:

• BPPV is a clinical diagnosis based on characteristic brief episodes (lasting <60 seconds) of vertigo with specific head positions, accompanied by characteristic nystagmus, but WITHOUT severe pain 1, 2
• The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that patients with BPPV typically describe discrete, episodic periods of vertigo lasting 1 minute or less, not continuous severe pain 2

Do not be falsely reassured by the attempt at Dix-Hallpike testing:

• The fact that vertigo was provoked does not confirm BPPV when severe pain is also present 2
• The absence of characteristic nystagmus findings (which cannot be assessed when the patient cannot tolerate the maneuver due to pain) should raise suspicion for alternative diagnoses 2

Do not delay imaging based on age or lack of obvious neurological deficits:

• MRI detected acute brain lesions in 11% of patients with episodic vertigo and negative/atypical Dix-Hallpike testing 2
• Isolated vascular vertigo without other obvious neurological signs is increasingly recognized 5