What is the best treatment approach for an adult patient presenting with vertigo and no significant medical history?

Treatment of Vertigo in Adults

The best treatment for vertigo depends entirely on the underlying cause, which must be identified through timing, triggers, and physical examination—with the Epley maneuver being first-line for BPPV (the most common cause), while medications play only a limited supportive role and should never replace definitive physical therapy or repositioning procedures. 1, 2

Initial Diagnostic Classification

The first critical step is determining the vertigo pattern based on timing and triggers, as this guides all subsequent management decisions: 1, 2

• Brief episodic vertigo (seconds to minutes) triggered by head position changes suggests BPPV—perform the Dix-Hallpike maneuver immediately 1, 2
• Spontaneous episodic vertigo (20 minutes to 12 hours) with hearing loss, tinnitus, or aural fullness indicates Ménière's disease 2, 3
• Acute persistent vertigo (days to weeks) suggests vestibular neuritis or, critically, posterior circulation stroke 1, 3
• Chronic vertigo (weeks to months) often results from medication side effects, anxiety, or incomplete recovery from prior vestibular injury 1

Critical pitfall: Never rely on the patient's description of "spinning" versus "lightheadedness"—focus exclusively on timing, triggers, and associated symptoms instead. 1

Physical Examination and Red Flags

Before initiating any treatment, perform a focused examination to exclude dangerous central causes: 1, 2, 3

• Perform the Dix-Hallpike maneuver bilaterally for all patients with suspected positional vertigo—positive findings show torsional upbeating nystagmus with 5-20 second latency that resolves within 60 seconds 1, 2
• Check for red flags mandating urgent MRI brain without contrast: 1, 2, 3
  • Focal neurological deficits on examination
  • Downbeating or direction-changing nystagmus without head position changes
  • Sudden unilateral hearing loss
  • Inability to stand or walk
  • New severe headache with vertigo
  • Neck stiffness (suggests stroke, meningitis, or posterior fossa lesion)
  • Age >50 with vascular risk factors (hypertension, diabetes, prior stroke, atrial fibrillation)

Critical pitfall: Up to 75-80% of posterior circulation strokes causing acute vestibular syndrome have NO focal neurologic deficits initially—a normal neurologic exam does NOT exclude stroke. 3 The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, but is unreliable when performed by non-experts. 1

Treatment by Specific Diagnosis

Benign Paroxysmal Positional Vertigo (BPPV)

The Epley maneuver is definitive first-line treatment with 80-93% success after 1-3 treatments and 90-98% success with repeat maneuvers—medications are unnecessary and should not be prescribed for typical BPPV. 1, 2

• Perform the canalith repositioning procedure (Epley maneuver) immediately upon diagnosis 1, 2
• No imaging or laboratory testing is indicated for patients with positive Dix-Hallpike test and no red flags 1, 2
• Reassess within 1 month to document resolution or persistence 1, 2
• If no improvement after repositioning maneuvers or atypical presentation, obtain MRI brain to exclude central causes, as 3% of BPPV treatment failures have CNS disorders masquerading as BPPV 2

Critical pitfall: Do NOT perform Dix-Hallpike when neck stiffness is present, as this may indicate serious central pathology. 3

Acute Vestibular Neuritis or Labyrinthitis

For acute persistent vertigo lasting days with severe nausea/vomiting and no hearing loss: 3, 4

• Initial stabilization (first 24-48 hours only): Vestibular suppressants may be used briefly to control severe symptoms, but must be discontinued quickly to avoid delaying central compensation 4, 5
• Meclizine 25-100 mg daily in divided doses can be used for short-term symptom control in vestibular disorders 6, though evidence shows physical therapy is superior to medications 5
• Vestibular rehabilitation therapy is the primary intervention and should begin as soon as acute symptoms subside—this significantly improves gait stability compared to medication alone 1, 5

Critical pitfall: Prolonged use of vestibular suppressants (>48-72 hours) delays central compensation and worsens long-term outcomes. 5

Ménière's Disease

For episodic vertigo lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, or aural fullness: 2, 3

• First-line therapy: Dietary sodium restriction combined with diuretics 2
• Consider betahistine to increase inner ear vasodilation 2
• Obtain audiogram to document low-to-mid frequency sensorineural hearing loss 1
• Reserve destructive interventions for severe progressive hearing loss or lack of usable hearing 1

Vestibular Migraine

For vertigo with current/past migraine history, headache, photophobia, or phonophobia: 1, 2

• Migraine prophylaxis: Tricyclic antidepressant plus beta blocker or calcium channel blocker 5
• Dietary modifications and lifestyle changes 1, 2
• Motion intolerance and light sensitivities help differentiate from Ménière's disease 1

Note: Vestibular migraine accounts for 14% of all vertigo cases but is extremely under-recognized, particularly in young patients. 1

Imaging Decisions

No imaging is indicated for: 1, 2

• Brief episodic vertigo with typical BPPV features and positive Dix-Hallpike test
• Acute persistent vertigo with normal neurologic exam and peripheral HINTS findings (by trained examiner)

MRI brain without contrast is mandatory for: 1, 2, 3

• Any red flags listed above
• High vascular risk patients with acute vestibular syndrome (even with normal neurologic exam, as 11-25% may have posterior circulation stroke)
• Abnormal neurologic examination or HINTS suggesting central cause
• Unilateral or pulsatile tinnitus with asymmetric hearing loss

Critical pitfall: CT head has extremely low diagnostic yield (<1%) for isolated dizziness and misses most posterior circulation infarcts with only 20-40% sensitivity—if stroke is suspected, MRI with diffusion-weighted imaging is mandatory (4% diagnostic yield vs <1% for CT). 1, 3

Vestibular Rehabilitation

Vestibular rehabilitation therapy is indicated for: 1, 2

• Persistent dizziness from any vestibular cause that fails initial treatment
• Chronic imbalance or incomplete recovery
• Elderly patients or those with heightened fall risk (dizziness increases fall risk 12-fold in elderly patients) 1

This can be self-administered or therapist-directed and includes habituation exercises, gaze stabilization, balance retraining, and fall prevention strategies. 1

Medication Considerations

Review and discontinue offending medications, as medication side effects are a leading reversible cause of chronic dizziness: 1

• Antihypertensives
• Sedatives
• Anticonvulsants
• Psychotropic drugs

Meclizine limitations: While FDA-approved for vertigo associated with vestibular system diseases 6, meclizine causes drowsiness, has anticholinergic effects (use with caution in asthma, glaucoma, prostate enlargement), and should never replace definitive physical therapy for BPPV or vestibular rehabilitation for other causes. 6, 5

Special Considerations for Elderly Patients

• BPPV is present in 9% of elderly patients referred for geriatric evaluation, with three-fourths having fallen within the prior 3 months 1
• Counsel on fall risk, home safety assessment, and activity restrictions until resolved 1
• Consider home supervision if elderly and frail 1
• Check fingerstick glucose immediately, as hypoglycemia is the most frequently identified unexpected abnormality in elderly patients with dizziness 1

Common Pitfalls to Avoid

• Assuming anxiety is the cause before excluding central pathology—anxiety is often a secondary response to acute vestibular dysfunction 3
• Ordering CT instead of MRI when stroke is suspected 3
• Performing Dix-Hallpike when neck stiffness is present 3
• Prescribing medications for BPPV instead of performing the Epley maneuver 2
• Prolonged use of vestibular suppressants beyond 48-72 hours 5
• Failing to obtain MRI in high vascular risk patients even with normal neurologic exam 1, 3