What causes vertigo upon waking, and how should it be treated?

Vertigo Upon Waking: Causes and Treatment

Vertigo upon waking is most commonly caused by benign paroxysmal positional vertigo (BPPV), which should be immediately diagnosed with the Dix-Hallpike maneuver and treated with the Epley maneuver—not vestibular suppressant medications. 1

Most Likely Diagnosis

BPPV accounts for 42% of all vertigo cases and is the single most common cause of positional vertigo triggered by head position changes, including rolling over in bed or getting up in the morning. 1

• Episodes characteristically last less than 1 minute and are triggered by specific head/body position changes 1
• The condition results from mobile debris (canaliths) in the vestibular labyrinth 1

Immediate Diagnostic Approach

Perform the Dix-Hallpike maneuver bilaterally immediately upon presentation to confirm or exclude BPPV 1

Positive BPPV findings on Dix-Hallpike:

• Peripheral torsional and upbeating nystagmus with 5-20 second latency 1
• Crescendo-decrescendo pattern 1
• Fatigues with repeat testing 1
• Resolves within 60 seconds 1

Red flags suggesting dangerous central causes requiring urgent neuroimaging:

• Immediate onset nystagmus without latency 1
• Purely vertical nystagmus without torsional component 1
• Persistent nystagmus that does not fatigue 1
• Severe postural instability with falling 1
• New-onset severe headache with vertigo 1
• Any additional neurological symptoms (dysarthria, diplopia, limb weakness, sensory deficits) 1

First-Line Treatment

If Dix-Hallpike is positive for BPPV, perform the Epley maneuver (canalith repositioning procedure) immediately upon diagnosis 1

• Success rate of 80% after 1-3 treatments 1
• 90-98% success with additional maneuvers if initial treatment fails 1
• Do NOT prescribe vestibular suppressant medications for BPPV as they prevent central compensation and are inappropriate for this condition 1, 2
• No postprocedural postural restrictions are necessary 1

Alternative Diagnoses to Consider

Vestibular Neuritis/Labyrinthitis

• Presents with acute prolonged vertigo lasting 12-36 hours to days 3
• Vestibular neuritis: vertigo without hearing loss 3
• Labyrinthitis: vertigo with hearing loss 3
• Treatment: initial vestibular suppressants (meclizine 25-100 mg daily in divided doses) 4, followed by vestibular rehabilitation 1

Ménière's Disease

• Episodic vertigo lasting hours with the classic triad: fluctuating sensorineural hearing loss, tinnitus, and aural fullness 1
• Episodes are spontaneous, not triggered by position changes 1
• Treatment: dietary sodium restriction, diuretics, and vestibular rehabilitation 1

Vestibular Migraine

• Lifetime prevalence of 3.2%, accounts for up to 14% of vertigo cases 1
• Episodes can be short (<15 minutes) or prolonged (>24 hours) 1
• Distinguished from Ménière's by stable or absent hearing loss (not fluctuating) 1
• Associated with photophobia, phonophobia, or visual aura during at least 50% of episodes 1

When Imaging IS Required

Approximately 25% of patients with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 1

Obtain urgent MRI brain with diffusion-weighted imaging for: 1

• Severe postural instability with falling
• Downbeating nystagmus without torsional component
• Failure to respond to appropriate peripheral vertigo treatments
• Baseline nystagmus present without provocative maneuvers
• Any additional neurologic symptoms

When Imaging is NOT Required

Do not obtain neuroimaging in patients meeting BPPV diagnostic criteria with typical Dix-Hallpike findings and no red flags 1

• Routine CT head for isolated dizziness has diagnostic yield <1% 1
• MRI diagnostic yield is only 4% in isolated dizziness 1

Follow-Up

Reassess within 1 month after initial treatment to document resolution or persistence of symptoms 1

• If symptoms persist, repeat Dix-Hallpike test to confirm ongoing BPPV 1
• Perform additional canalith repositioning maneuvers with 90-98% success rate 1

Critical Pitfalls to Avoid

• Approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders—always assess for red flags 1
• Never prescribe vestibular suppressants for BPPV—they are contraindicated and prevent compensation 1, 2
• Missing central causes by failing to perform proper nystagmus examination 1
• Overlooking medication side effects (antihypertensives, cardiovascular drugs, anticonvulsants) as causes of dizziness 1