How can a vertigo episode be managed or alleviated?

Acute Vertigo Episode Management

For an acute vertigo episode, immediately perform the Dix-Hallpike maneuver to diagnose BPPV (the most common cause), then treat with the Epley maneuver (canalith repositioning procedure) which provides 70-80% resolution within 48 hours—avoid vestibular suppressant medications as primary treatment since they lack evidence for effectiveness in BPPV and interfere with natural compensation mechanisms. 1

Immediate Diagnostic Approach

• Perform the Dix-Hallpike maneuver first to identify posterior canal BPPV, which accounts for 85-95% of peripheral vertigo cases—this involves bringing the patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus with 5-20 second latency 1, 2

• If Dix-Hallpike is negative but vertigo persists, perform the supine roll test to assess for lateral (horizontal) canal BPPV, which accounts for 10-15% of cases—this involves turning the head rapidly 90° to each side while supine, observing for horizontal nystagmus 1, 2

• Do not order imaging or vestibular testing unless atypical neurological signs are present (abnormal cranial nerves, severe headache, visual disturbances) 1

Treatment Algorithm by Canal Type

Posterior Canal BPPV (85-95% of cases)

• Perform the Epley maneuver immediately upon diagnosis without any medications—this achieves 80% success after 1-3 treatments and 90-98% after repeat maneuvers if needed 1, 2

• The Epley maneuver involves: patient sitting upright with head turned 45° toward affected ear → rapidly lay back to supine head-hanging 20° position for 20-30 seconds → turn head 90° toward unaffected side → roll patient onto side with nose pointing down 45° → return to sitting position 1

• Alternative: Semont (Liberatory) Maneuver has 94.2% resolution rate at 6 months and involves rapid side-to-side movements 1, 3

Lateral Canal BPPV (10-15% of cases)

• For geotropic variant: Use Gufoni maneuver (93% success rate) or Barbecue Roll maneuver (75-90% effectiveness) 1, 2

• For apogeotropic variant: Use Modified Gufoni maneuver where patient lies on the affected side 1

Medication Management: When and What to Use

Vestibular Suppressants (Limited Role)

• Do NOT routinely prescribe meclizine, antihistamines, or benzodiazepines for BPPV treatment—there is no evidence they work as definitive treatment and they cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk, and interference with central compensation 4, 1

• Only consider vestibular suppressants for short-term management (during acute attacks only) of severe nausea/vomiting in patients refusing other treatment or requiring prophylaxis immediately before/after repositioning procedures 4

• Benzodiazepines carry significant risk for drug dependence and should be used sparingly 4

• Anticholinergic drugs (scopolamine, atropine) can suppress acute vertigo but cause blurring of vision, dry mouth, dilated pupils, urinary retention, and sedation—not commonly prescribed due to side-effect profile 4

Meclizine FDA-Approved Use

• Meclizine is FDA-approved for treatment of vertigo associated with vestibular system diseases in adults, but should not be used as primary treatment for BPPV 5

Critical Post-Treatment Instructions

• Patients can resume normal activities immediately after canalith repositioning procedures—postprocedural restrictions provide no benefit and may cause unnecessary complications 1, 2

• Reassess within 1 month to confirm symptom resolution 1

• Mild postural instability lasting up to 24 hours with tendency to fall backward or forward is common and expected 1

Management of Treatment Failures

If Symptoms Persist After Initial Treatment

• Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV—repeat repositioning maneuvers achieve 90-98% success rates 1

• Check for canal conversion (occurs in 6-7% of cases)—posterior canal may convert to lateral canal or vice versa, requiring different treatment approach 1

• Evaluate for multiple canal involvement—initial treatment may have targeted the wrong canal 1

• Rule out coexisting vestibular dysfunction if symptoms are provoked by general head movements or occur spontaneously 1

• Consider CNS disorders masquerading as BPPV if atypical features are present (continuous vertigo, severe headache, neurological deficits) 1

Adjunctive Vestibular Rehabilitation Therapy

• Add vestibular rehabilitation exercises after successful repositioning to reduce future recurrence rates by approximately 50% 1

• VRT is particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk after successful repositioning 1

• Patients treated with repositioning plus VRT show significantly improved gait stability compared to repositioning alone 1

Special Populations and Contraindications

Assess Before Treatment

• Evaluate for contraindications including severe cervical stenosis or radiculopathy, severe rheumatoid arthritis or ankylosing spondylitis, known cerebrovascular disease, severe kyphoscoliosis, or limited cervical range of motion 1

• For patients with contraindications: Consider Brandt-Daroff exercises (though less effective: 24% vs 71-74% success rate at 1 week) or refer to specialized vestibular physical therapy 1

High-Risk Patients

• Elderly patients warrant particular attention—BPPV increases fall risk 12-fold, and 9% of patients referred to geriatric clinics have undiagnosed BPPV with three-quarters having fallen within the previous 3 months 1

• Address fall risk immediately with home safety assessment, activity restrictions, and need for supervision 1

Self-Treatment Options

• Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment—shows 64% improvement compared to 23% with Brandt-Daroff exercises 1

Common Pitfalls to Avoid

• Failing to identify the affected canal before treatment leads to ineffective treatment 1

• Not moving the patient quickly enough during maneuvers reduces effectiveness 1

• Prescribing vestibular suppressants as primary treatment delays definitive care and exposes patients to unnecessary medication risks 1

• Imposing postprocedural restrictions provides no benefit and may cause complications 1

• Not reassessing treatment failures within appropriate timeframe misses opportunities for successful repeat treatment 1