What is the initial treatment for a patient presenting with acute vertigo?

Initial Treatment for Acute Vertigo

The initial treatment for acute vertigo depends critically on distinguishing between benign paroxysmal positional vertigo (BPPV) and acute vestibular syndrome (AVS), with BPPV requiring immediate canalith repositioning procedures and AVS requiring vestibular suppressants only for severe nausea in the first 24-48 hours, followed by early vestibular rehabilitation. 1, 2

Immediate Diagnostic Approach

The first step is determining the timing pattern of vertigo to guide treatment:

• For episodic vertigo triggered by position changes: Perform the Dix-Hallpike maneuver immediately at bedside to diagnose posterior canal BPPV (85-95% of BPPV cases), looking for torsional upbeating nystagmus 1, 3
• If Dix-Hallpike is negative but history suggests BPPV: Perform the supine roll test to assess for lateral canal BPPV (10-15% of cases), observing for horizontal nystagmus 1, 4
• For continuous vertigo lasting hours to days: This represents AVS and requires distinguishing peripheral (vestibular neuritis) from central causes (stroke) using the HINTS examination if trained, or neurologic examination 1, 5

Treatment Algorithm for BPPV (Episodic Positional Vertigo)

Perform canalith repositioning immediately upon diagnosis—do not prescribe medications or order imaging:

Posterior Canal BPPV (Most Common)

• Execute the Epley maneuver immediately with 80% success rate after 1-3 treatments 1, 4, 3
• The maneuver involves: patient sitting upright with head turned 45° toward affected ear, rapidly laying back to supine head-hanging 20° position for 20-30 seconds, turning head 90° toward unaffected side, rolling patient onto side, and returning to upright position 4
• Alternative: Semont (Liberatory) maneuver with 94.2% resolution at 6 months 1, 4

Lateral Canal BPPV

• Geotropic variant: Barbecue Roll (Lempert) maneuver with 50-100% success rate, or Gufoni maneuver with 93% success 4
• Apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side) 4

Critical Post-Treatment Instructions

• Patients can resume normal activities immediately—postprocedural restrictions provide no benefit and may cause unnecessary complications 1, 4
• Reassess within 1 month to confirm symptom resolution 1, 2

Treatment Algorithm for AVS (Continuous Acute Vertigo)

Acute Phase (First 24-48 Hours Only)

Vestibular suppressants should be used sparingly and only for severe nausea/vomiting:

• Levo-sulpiride IV 50 mg in 250 mL saline once or twice daily for neurovegetative symptoms 6
• Methoclopramide IM 10 mg once or twice daily as alternative 6
• Diazepam IM 10 mg once or twice daily to decrease internuclear inhibition 6
• Gabapentin PO 300 mg 2-3 times daily if patient can swallow, to reduce nystagmus and stabilize visual field 6

Critical Medication Warnings

Do NOT prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) beyond 48 hours as they impede central vestibular compensation and have significant adverse effects including drowsiness, cognitive deficits, and increased fall risk 2, 4, 7, 3

Early Vestibular Rehabilitation (Begin After 48-72 Hours)

• Start vestibular rehabilitation as soon as acute symptoms subside, typically after the first few days 2
• Include habituation exercises, adaptation exercises for gaze stabilization, and balance training 2
• This promotes central compensation and is the definitive treatment for vestibular neuritis 2

Medication Management: What NOT to Do

The most common error in emergency departments is prescribing meclizine or other vestibular suppressants as primary treatment:

• Meclizine is FDA-approved for vertigo but should NOT be routinely prescribed for BPPV or as long-term treatment for AVS 1, 4, 7, 3
• These medications cause drowsiness, cognitive deficits, increased fall risk (especially in elderly), and interfere with central compensation 4
• They have no evidence of effectiveness as definitive treatment for BPPV 1, 4

When Imaging Is Indicated

Do NOT order brain imaging for typical BPPV with positive Dix-Hallpike test 1, 3

DO order MRI brain (without and with contrast preferred) for:

• AVS with abnormal neurologic examination suggesting central cause 1
• AVS with high vascular risk factors (age >50, diabetes, hypertension, prior stroke) even without focal findings, as 25-75% of posterior circulation strokes present as isolated vertigo 1
• Atypical features: severe headache, diplopia, dysarthria, focal weakness, or HINTS examination suggesting central cause 1, 2
• Persistent symptoms after appropriate repositioning maneuvers for BPPV 1

Note that CT has very low yield (<1%) for detecting contributory pathology in isolated vertigo with normal neurologic exam 1

Treatment Failures and Reassessment

If symptoms persist after initial BPPV treatment:

• Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV 1, 4
• Repeat CRP achieves 90-98% success rates with additional maneuvers 1, 4
• Check for canal conversion (6-7% of cases switch from posterior to lateral canal or vice versa) 1, 4
• Evaluate for multiple canal involvement or bilateral BPPV 1
• Consider coexisting vestibular dysfunction if symptoms are provoked by general head movements rather than specific position changes 1
• Rule out CNS disorders masquerading as BPPV (3% of treatment failures) 1, 2

If AVS symptoms persist beyond 1 month:

• Evaluate for incomplete compensation, coexisting vestibular disorders, or central pathology 2
• Continue or intensify vestibular rehabilitation 2

Special Populations and Safety Considerations

Assess all patients before treatment for:

• Impaired mobility or balance requiring fall prevention strategies immediately 1, 4
• CNS disorders, cervical stenosis, severe rheumatoid arthritis, or cervical radiculopathy that may require modified approaches 1, 4
• Elderly patients have 12-fold increased fall risk with BPPV and warrant particular attention 4
• Patients with contraindications may need Brandt-Daroff exercises instead of standard maneuvers 4

Common Pitfalls to Avoid

• Prescribing meclizine or vestibular suppressants as primary treatment for BPPV—this is ineffective and delays proper treatment 1, 4, 3
• Ordering brain imaging for typical BPPV—this increases costs, radiation exposure, and ED length of stay without benefit 1, 3
• Imposing postprocedural restrictions after Epley maneuver—these provide no benefit 1, 4
• Prolonged use of vestibular suppressants in AVS—this impedes central compensation 2
• Failing to initiate early vestibular rehabilitation for AVS after acute phase 2
• Missing central causes in high-risk patients with isolated vertigo—maintain high suspicion for stroke in patients >50 with vascular risk factors 1, 2