What is the best approach to manage a patient with peripheral vertigo, considering their overall health status and potential for falls?

Management of Peripheral Vertigo

The best approach to managing peripheral vertigo prioritizes immediate diagnostic maneuvers (Dix-Hallpike and supine roll test) to identify BPPV, followed by canalith repositioning procedures as first-line treatment, while systematically assessing fall risk and excluding dangerous central causes before considering any pharmacologic therapy. 1

Initial Diagnostic Approach

Perform the Dix-Hallpike maneuver immediately in all patients presenting with vertigo to diagnose or exclude benign paroxysmal positional vertigo (BPPV), which accounts for 42% of peripheral vertigo cases. 1, 2 The maneuver involves bringing the patient from upright to supine with the head turned 45° to one side and neck extended 20°, repeating with the opposite ear if initially negative. 1

Positive Dix-Hallpike Findings (BPPV):

• Torsional and upbeating nystagmus with 5-20 second latency 2
• Crescendo-decrescendo pattern that fatigues with repeat testing 2
• Resolves within 60 seconds 2

Red Flags Requiring Urgent Neuroimaging:

• Immediate onset nystagmus without latency 2
• Purely vertical nystagmus without torsional component 1, 2
• Nystagmus that does not fatigue or suppress with visual fixation 1, 2
• Severe postural instability with falling 1
• Any additional neurologic symptoms (dysarthria, dysmetria, dysphagia, motor/sensory deficits) 1
• New-onset severe headache with vertigo 2

If horizontal or no nystagmus appears on Dix-Hallpike, perform the supine roll test to assess for lateral semicircular canal BPPV. 1

Immediate Treatment for Confirmed BPPV

Execute the canalith repositioning procedure (Epley maneuver) immediately upon diagnosis without delay. 1, 2 This achieves 80% success after 1-3 treatments and 90-98% success with additional maneuvers if initial treatment fails. 2

Critical Treatment Principles:

• Do not recommend postprocedural postural restrictions after canalith repositioning—they provide no benefit 1
• Do not prescribe vestibular suppressant medications (antihistamines like meclizine or benzodiazepines) routinely for BPPV, as they prevent central compensation and are not indicated for this condition 1, 3

Mandatory Fall Risk Assessment

Assess all patients with peripheral vertigo for modifying factors that increase morbidity and mortality, particularly fall risk. 1 Patients with dizziness have a 12-fold increased risk of falls, and 9% of elderly patients referred for geriatric evaluation have undiagnosed BPPV, with three-fourths having fallen within 3 months. 1

Specific Fall Risk Screening Questions:

• Have you fallen in the past year? How many times? Were you injured? 1
• Do you feel unsteady when standing or walking? 1
• Do you worry about falling? 1

Additional Modifying Factors to Assess:

• Impaired mobility or balance 1
• CNS disorders 1
• Lack of home support 1
• Medication review for vestibulotoxic agents (aminoglycosides, anticonvulsants, antihypertensives) 2

A positive response to any screening question warrants detailed falls risk assessment using validated tools like the Get Up and Go test or Tinetti Balance Assessment. 3

When NOT to Order Testing

Do not obtain radiographic imaging in patients meeting diagnostic criteria for BPPV with typical nystagmus on Dix-Hallpike testing, absent additional concerning signs or symptoms. 1 The diagnostic yield of CT for isolated dizziness is less than 1%. 1, 2

Do not order vestibular testing in patients meeting BPPV diagnostic criteria without additional vestibular signs/symptoms inconsistent with BPPV. 1

Alternative Peripheral Causes to Consider

If Dix-Hallpike is negative but peripheral vertigo is suspected based on nystagmus characteristics (horizontal with rotatory component, unidirectional, suppressed by visual fixation), consider:

Vestibular Neuritis (41% of peripheral vertigo cases):

• Acute onset severe vertigo lasting days to weeks 2
• Horizontal nystagmus that lessens with visual fixation 4
• No hearing loss, tinnitus, or aural fullness 4

Ménière's Disease (10-43% of cases):

• Episodes lasting 20 minutes to 12 hours 2, 4
• Fluctuating hearing loss (key distinguishing feature) 2
• Tinnitus and aural fullness 2, 4
• Obtain audiogram if suspected 4

Vestibular Migraine (14% of vertigo cases):

• Episodes lasting 5 minutes to 72 hours 1
• Migraine symptoms during at least 50% of dizzy episodes (headache, photophobia, phonophobia, visual aura) 1, 2
• Stable or absent hearing loss (not fluctuating like Ménière's) 2

Treatment Options Beyond Canalith Repositioning

Vestibular rehabilitation (self-administered or clinician-guided) may be offered as an adjunct treatment option for BPPV or as primary therapy for vestibular neuritis. 1

Observation with follow-up may be offered as initial management for patients with BPPV who prefer conservative approach. 1

Mandatory Reassessment and Follow-Up

Reassess all patients within 1 month after initial observation or treatment to document resolution or persistence of symptoms. 1, 2

If Symptoms Persist:

• Repeat Dix-Hallpike test to confirm ongoing BPPV 2
• Perform additional canalith repositioning maneuvers (90-98% success with repeated procedures) 2
• Evaluate for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders if treatment fails 1
• Failure to respond to conservative management should raise concern that the diagnosis may not be BPPV 1

Patient Education Priorities

Educate all patients regarding:

• Impact of BPPV on their safety, particularly fall risk 1
• Potential for disease recurrence 1
• Importance of follow-up 1

Common Pitfalls to Avoid

• Prescribing vestibular suppressants for BPPV—these medications (meclizine, benzodiazepines) prevent central compensation and are not indicated despite FDA approval for "vertigo associated with vestibular system diseases" 1, 5
• Assuming normal neurologic exam excludes stroke—up to 75-80% of posterior circulation strokes causing acute vestibular syndrome have no focal neurologic deficits initially 4
• Ordering CT instead of MRI when central cause suspected—CT has only 20-40% sensitivity for posterior circulation infarcts 4
• Overlooking 10% of cerebellar strokes that present identically to peripheral vestibular disorders 1, 2
• Missing multiple concurrent vestibular disorders (e.g., BPPV with Ménière's disease) 2