What could be causing acute nausea and dizziness in a patient after looking too fast to the side while indoors?

Acute Nausea and Dizziness After Rapid Head Movement: Benign Paroxysmal Positional Vertigo (BPPV)

This presentation is classic for Benign Paroxysmal Positional Vertigo (BPPV), the most common cause of vertigo triggered by rapid head movements, and should be diagnosed with the Dix-Hallpike maneuver and treated immediately with canalith repositioning procedures (Epley maneuver). 1, 2

Clinical Diagnosis

• BPPV causes brief spinning episodes lasting seconds to less than one minute, triggered specifically by head position changes such as looking quickly to the side, rolling over in bed, or looking up 1, 2, 3

• The nausea accompanying the vertigo is a common associated symptom, along with a severe sense of disorientation, though the most intense symptoms typically last only seconds to minutes 1

• The Dix-Hallpike maneuver is the gold standard diagnostic test and should be performed immediately in any patient with brief episodic dizziness triggered by position changes 1, 2, 3

• Diagnostic criteria for a positive Dix-Hallpike include: a latency period of 5-20 seconds before symptoms begin, torsional upbeating nystagmus toward the affected ear, and vertigo/nystagmus that increase then resolve within 60 seconds 2, 3

Immediate Management

• Perform the canalith repositioning procedure (Epley maneuver) immediately upon diagnosis—this is first-line treatment with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers 1, 2, 3

• No imaging or laboratory testing is needed for patients who meet diagnostic criteria for BPPV with a positive Dix-Hallpike test and no additional concerning neurologic features 2, 3

• Medications such as meclizine are not necessary for typical BPPV and should only be used for immediate symptom relief of severe nausea if needed 1, 4

Critical Red Flags Requiring Different Evaluation

If any of the following are present, this is NOT simple BPPV and requires urgent neuroimaging (MRI brain without contrast): 1, 2

• Focal neurological deficits (dysarthria, diplopia, numbness, weakness, dysphagia) 1, 2, 3
• Inability to stand or walk independently 1, 2
• Downbeating nystagmus or other central nystagmus patterns (nystagmus without the typical torsional component, direction-changing nystagmus without head position changes) 1
• Sudden unilateral hearing loss 2, 3
• New severe headache accompanying the dizziness 2, 3
• Symptoms lasting continuously for hours to days rather than brief episodes 2, 5, 6

Common Diagnostic Pitfalls to Avoid

• Do not skip the Dix-Hallpike maneuver—it is the definitive diagnostic test and performing it allows immediate treatment 2, 3

• Do not assume a normal neurologic exam excludes stroke—75-80% of patients with posterior circulation stroke from acute vestibular syndrome have no focal neurologic deficits 2

• However, BPPV presents as triggered episodic vestibular syndrome (brief episodes with specific triggers), not acute vestibular syndrome (continuous symptoms lasting days), making stroke extremely unlikely in this presentation 5, 6

• Do not order imaging for straightforward BPPV—this delays effective treatment unnecessarily and has extremely low diagnostic yield 2, 3

• Do not rely on the patient's description of "spinning" versus other dizziness descriptors; instead focus on the timing (seconds duration) and specific trigger (head movement) 2, 5, 6

Follow-Up Considerations

• Patients should be counseled about the possibility of recurrence and instructed to return promptly for repeat repositioning procedures if symptoms recur 1, 2

• If symptoms persist despite appropriate canalith repositioning procedures, or if atypical symptoms develop (persistent hearing loss, gait disturbance, non-positional vertigo), further evaluation is warranted as this may indicate an underlying concurrent vestibular or CNS disorder 1

• Vestibular rehabilitation therapy should be considered for persistent dizziness that fails initial treatment 1, 2