What is the best course of treatment for a patient who was in a motor vehicle accident (MVA) and is now presenting with dizziness?

Post-MVA Dizziness: Evaluation and Management

For a patient presenting with dizziness after a motor vehicle accident, immediately perform a focused neurologic examination and Dix-Hallpike maneuver to distinguish between benign posttraumatic BPPV and dangerous central pathology requiring urgent imaging. 1

Immediate Clinical Assessment

Critical Red Flags Requiring Urgent Imaging

Perform a complete neurologic examination looking for:

• Focal neurologic deficits (weakness, numbness, dysarthria, diplopia) 1, 2
• Inability to stand or walk 1, 2
• New severe headache accompanying the dizziness 1, 2
• Downbeating nystagmus or other central nystagmus patterns 1, 2
• Sudden unilateral hearing loss 1, 2

If ANY red flags are present, obtain MRI brain without contrast immediately and consult neurology. 1, 3 CT head has extremely low diagnostic yield (<1%) and misses most posterior circulation infarcts. 1, 3

Categorize by Timing and Triggers

Focus on specific diagnostic details rather than vague patient descriptions: 1, 4

• Brief episodic vertigo (seconds to minutes) triggered by head position changes suggests posttraumatic BPPV 1, 4
• Acute persistent vertigo (days to weeks) with constant symptoms suggests vestibular neuritis or central pathology 1, 4
• Chronic symptoms (weeks to months) suggest posttraumatic vertigo syndrome 1, 2

Diagnostic Testing Algorithm

For Brief Episodic Positional Dizziness

Perform the Dix-Hallpike maneuver immediately. 1, 4 Diagnostic criteria for BPPV include:

• 5-20 second latency before symptoms begin 1, 4
• Torsional upbeating nystagmus toward the affected ear 1, 4
• Vertigo and nystagmus that increase then resolve within 60 seconds 1, 4

If Dix-Hallpike is positive with typical features, NO imaging is required. 1 Proceed directly to treatment with canalith repositioning procedures. 1, 4

For Acute Persistent Vertigo

Perform the HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained in this technique. 1, 4 The HINTS exam has 100% sensitivity for detecting stroke when performed by trained practitioners. 1, 4

HINTS findings suggesting CENTRAL cause (requires immediate MRI): 1, 3

• Normal head impulse test (eyes do NOT catch up with saccade)
• Direction-changing nystagmus
• Skew deviation present

However, given the trauma history, maintain a lower threshold for imaging. Posttraumatic BPPV is significantly more likely to be bilateral and require repeated treatments (up to 67% vs 14% in non-traumatic cases). 1

Imaging Decisions Post-Trauma

Obtain MRI brain without contrast if: 1, 3

• Any red flag symptoms present
• Abnormal neurologic examination
• HINTS examination suggests central cause
• High vascular risk factors (age >50, hypertension, diabetes, prior stroke) 1, 2
• Atypical nystagmus patterns 1, 3
• Symptoms refractory to appropriate treatment 1

Do NOT obtain CT head as initial imaging for isolated dizziness—it has <1% diagnostic yield and misses posterior circulation infarcts. 1, 3 MRI with diffusion-weighted imaging is far superior (4% diagnostic yield vs <1% for CT). 1, 3

Treatment Based on Diagnosis

Posttraumatic BPPV (Most Common)

Perform canalith repositioning procedures (Epley maneuver) immediately with 80% success after 1-3 treatments and 90-98% success with repeat maneuvers. 1, 4

Critical caveat: Posttraumatic BPPV may require repeated treatments and can be bilateral, so reassess within one month. 1 Consider cervical spine precautions during repositioning if neck injury is suspected. 1

Vestibular Suppressants (Limited Role)

Meclizine is FDA-approved for vertigo associated with vestibular system diseases 5, but use sparingly and only for acute symptom relief as it delays central compensation. 6, 7 Avoid in patients requiring vestibular rehabilitation. 6

Vestibular Rehabilitation Therapy

Refer for vestibular rehabilitation if: 1, 4

• Symptoms persist despite initial treatment
• Patient has impaired mobility or balance
• Elderly patient with fall risk
• Concurrent CNS disorders 1

Vestibular rehabilitation significantly improves gait stability compared to medication alone. 1, 4

Special Considerations for Trauma Patients

Assess Modifying Factors

Document: 1

• Number of falls in past year and circumstances
• Impaired mobility or balance requiring home supervision
• Concurrent CNS disorders from the trauma
• Medications that may worsen dizziness (antihypertensives, sedatives) 1, 2

Posttraumatic Vertigo Syndrome

If symptoms persist chronically (weeks to months), consider posttraumatic vertigo characterized by: 1, 2

• History of head trauma
• Persistent vertigo, disequilibrium, tinnitus, and headache
• May require psychiatric evaluation for anxiety/panic disorder 1, 2

Fall Prevention Counseling

Dizziness increases fall risk 12-fold in elderly patients. 2 Provide: 1, 2

• Home safety assessment
• Activity restrictions until resolved
• Counseling about recurrence risk (10-18% at one year) 4
• Instructions to return promptly if symptoms recur 4

Common Pitfalls to Avoid

• Do NOT rely on patient's description of "spinning" vs "lightheadedness"—focus on timing and triggers instead 1, 4
• Do NOT assume normal neurologic exam excludes stroke—75-80% of posterior circulation infarct patients have no focal deficits 1, 2
• Do NOT order routine imaging for typical BPPV with positive Dix-Hallpike 1
• Do NOT use CT instead of MRI when stroke is suspected 1, 3
• Do NOT overlook bilateral BPPV in trauma patients—it occurs more commonly than in spontaneous cases 1