What are the best management options for a patient presenting with vertigo, with or without a history of migraines or benign paroxysmal positional vertigo (BPPV)?

Vertigo Management

For patients presenting with vertigo, perform the Dix-Hallpike maneuver immediately and treat confirmed BPPV with canalith repositioning procedures (Epley maneuver) as first-line therapy—do not use vestibular suppressant medications routinely for BPPV. 1

Initial Diagnostic Approach

Classify by Timing and Triggers

The key to managing vertigo is categorizing it by temporal pattern rather than relying on patient descriptions of "spinning" or "dizziness" 2:

• Triggered episodic vertigo (seconds to <1 minute, provoked by head position changes): Most likely BPPV, which accounts for 42% of peripheral vertigo cases 2
• Acute vestibular syndrome (continuous symptoms lasting days to weeks): Consider vestibular neuritis (41% of cases), labyrinthitis, or posterior circulation stroke 2
• Spontaneous episodic vertigo (minutes to hours, no positional trigger): Suspect vestibular migraine or Ménière's disease 2
• Chronic vestibular syndrome (weeks to months): Consider medication side effects, anxiety disorders, or posterior fossa masses 2

Perform Diagnostic Maneuvers

For suspected BPPV (brief positional vertigo):

• Execute the Dix-Hallpike maneuver bilaterally—bring patient from upright to supine with head turned 45° to one side and neck extended 20°, then repeat with opposite ear down 1
• Positive findings: Torsional upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, fatigues with repeat testing, resolves within 60 seconds 2, 3
• If Dix-Hallpike shows horizontal or no nystagmus, perform supine roll test to assess for lateral canal BPPV 1

Red flags indicating central pathology requiring urgent imaging: 2, 3

• Purely vertical nystagmus without torsional component
• Direction-changing nystagmus without head position changes
• Baseline nystagmus present without provocative maneuvers
• Immediate onset nystagmus without latency period
• Non-fatigable nystagmus on repeat testing
• Severe postural instability with inability to stand/walk
• New-onset severe headache
• Any focal neurological deficits

Treatment by Diagnosis

BPPV (Posterior Canal)

Primary treatment: 1, 3

• Perform canalith repositioning procedure (Epley maneuver) immediately upon diagnosis
• Success rate: 80% after 1-3 treatments, 90-98% with additional maneuvers if initial treatment fails 1, 3
• Do NOT prescribe postprocedural postural restrictions—strong recommendation against this practice 1
• Do NOT routinely prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) for BPPV 1, 3
• Meclizine may only be considered for severe nausea/vomiting during the maneuver itself, limited to 3-5 days maximum 3

For treatment failures: 1

• Repeat Dix-Hallpike test to confirm persistent BPPV
• Perform additional canalith repositioning maneuvers—success reaches 90-98% with repeated procedures 1
• If refractory to multiple repositioning attempts, consider surgical plugging of posterior semicircular canal or singular neurectomy (>96% success rate), though data quality limits definitive recommendations 1

Vestibular Migraine (in patients with migraine history)

Diagnostic criteria: 2

• Episodic vestibular symptoms with migraine features
• Migraine symptoms (photophobia, phonophobia, visual aura) during at least two vertiginous episodes
• Episodes can be brief (<15 minutes) or prolonged (>24 hours)
• Hearing loss is typically mild, absent, or stable—NOT fluctuating like Ménière's disease 2

Treatment: 2, 3

• Migraine prophylaxis and lifestyle modifications
• Vestibular rehabilitation for persistent symptoms 3
• Note: Vestibular migraine is extremely common (14% of all vertigo cases) but frequently under-recognized 2

Ménière's Disease

Distinguishing features: 2, 3

• Classic triad: Episodic vertigo lasting hours, fluctuating sensorineural hearing loss, tinnitus, and aural fullness
• Key difference from vestibular migraine: Progressive fluctuating hearing loss that worsens over time 2

Treatment: 3

• Dietary sodium restriction (1500-2300 mg daily) as first-line preventive therapy
• Diuretics combined with salt restriction
• Limit alcohol and caffeine intake
• Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) for acute vertigo attacks only
• Consider betahistine to increase inner ear vasodilation 3

Vestibular Neuritis/Labyrinthitis

Treatment: 3

• Short-term vestibular suppressants for symptomatic relief (maximum 3-5 days)
• Vestibular rehabilitation as primary intervention for persistent symptoms 3

Medication Guidelines

When Vestibular Suppressants Are Appropriate

Meclizine (FDA-approved for vertigo associated with vestibular system diseases) 4:

• Indicated for: Acute vertigo attacks in Ménière's disease, vestibular neuritis, or severe nausea during repositioning maneuvers 3
• Dosage: 25-100 mg daily in divided doses 3, 4
• Duration: Maximum 3-5 days to avoid interfering with central compensation 3, 5

Contraindications and Warnings 3, 4

• Use with extreme caution in elderly patients—increased fall risk, drowsiness, cognitive deficits
• Contraindicated in patients with asthma, glaucoma, or prostate enlargement
• Anticholinergic effects: dry mouth, blurred vision, urinary retention
• Avoid in patients taking other CNS depressants or alcohol
• May impair driving ability
• CYP2D6 inhibitors may increase meclizine levels 4

Assessment of Modifying Factors

Evaluate all patients for factors requiring modified management 1:

• Impaired mobility or balance: Increases fall risk 12-fold in elderly patients 2
• CNS disorders: Posttraumatic BPPV requires repeated treatments in 67% of cases vs. 14% for non-traumatic forms 1
• Lack of home support: May require temporary supervision or nursing home placement for safety 1
• Medication review: Antihypertensives, anticonvulsants, cardiovascular drugs, and psychotropic medications are leading causes of chronic dizziness 2, 6

When NOT to Order Testing

Do NOT obtain: 1, 2

• Radiographic imaging in patients meeting BPPV diagnostic criteria without additional concerning signs/symptoms
• Vestibular testing in patients with confirmed BPPV and typical presentation
• Routine CT head for isolated dizziness (diagnostic yield <1%) 2, 6
• Comprehensive laboratory panels—check fingerstick glucose only; other labs rarely change management 6

DO obtain MRI brain without contrast for: 2, 6

• High vascular risk patients (age >50, hypertension, diabetes, prior stroke) with acute vestibular syndrome—11-25% have posterior circulation stroke
• Abnormal neurologic examination
• HINTS examination suggesting central cause
• Unilateral or pulsatile tinnitus
• Asymmetric hearing loss
• Any red flags listed above

Follow-Up and Reassessment

• Reassess within 1 month after initial observation or treatment to document resolution or persistence 1
• For persistent symptoms after initial therapy, repeat Dix-Hallpike to confirm ongoing BPPV vs. other vestibular pathology 1
• Educate patients about BPPV recurrence risk, fall prevention, and importance of returning promptly for repeat repositioning if symptoms recur 1, 3

Vestibular Rehabilitation

Indications: 3

• Persistent dizziness from any vestibular cause after initial treatment
• Chronic imbalance or incomplete recovery
• Elderly patients or those with heightened fall risk
• Can be self-administered or therapist-directed
• Significantly improves gait stability compared to medication alone 3

Common Pitfalls to Avoid

• Prescribing vestibular suppressants for BPPV: These medications have lower efficacy (30.8%) compared to repositioning maneuvers (78.6-93.3%) and prevent central compensation 3
• Missing vestibular migraine: Extremely common (14% of vertigo cases) but frequently under-recognized, especially in young women with migraine history 2
• Failing to distinguish Ménière's from vestibular migraine: Key is fluctuating progressive hearing loss (Ménière's) vs. stable/absent hearing loss (vestibular migraine) 2
• Assuming normal neurologic exam excludes stroke: 75-80% of posterior circulation infarcts present without focal deficits 6
• Ordering CT instead of MRI for suspected stroke: CT misses most posterior circulation infarcts 2, 6
• Overlooking medication side effects: Review all antihypertensives, sedatives, anticonvulsants, and psychotropic drugs as reversible causes 2, 6
• Missing concurrent diagnoses: 35% of Ménière's patients also meet criteria for vestibular migraine; BPPV can coexist with other vestibular disorders 1, 2