What should a 35-year-old healthy male, with no medical history, who recently experienced a head fall during a ski trip and is now suffering from severe vertigo episodes, nausea, vomiting, and occasional ear pain, and is currently on betahistine 14 mg twice daily, do to manage his symptoms and prevent future episodes?

Immediate Management: Stop Betahistine and Perform Dix-Hallpike Testing

You need to stop betahistine immediately and undergo Dix-Hallpike testing for benign paroxysmal positional vertigo (BPPV), as your symptom pattern—positional vertigo triggered by turning over in bed that resolves between episodes—is classic for BPPV, not Ménière's disease or other conditions for which betahistine is indicated. 1, 2

Why This is BPPV, Not Another Condition

Your presentation is textbook BPPV:

• Positional trigger: Vertigo occurs specifically when turning over in bed, not spontaneously 1
• Brief but severe episodes: The spinning sensation is triggered by position changes and settles when you remain still 1
• Complete resolution between attacks: You feel "very normal as if nothing is wrong" between episodes, which is characteristic of BPPV 1
• No hearing loss, tinnitus, or persistent aural fullness: These would be required for Ménière's disease diagnosis 1
• Temporal relationship to head trauma: Your ski fall 4 weeks before symptom onset is a known precipitant of BPPV 1

The ear pain when chewing is likely temporomandibular joint (TMJ) dysfunction from the head trauma, not an inner ear pathology requiring betahistine 1.

Why Betahistine is Wrong for You

Betahistine is not indicated for BPPV and should not be used as primary treatment. 1, 3

• The American Academy of Otolaryngology explicitly recommends against vestibular suppressant medications for BPPV treatment 1
• Betahistine is indicated only for Ménière's disease maintenance therapy, which requires 2+ episodes of vertigo lasting 20 minutes to 12 hours PLUS fluctuating hearing loss, tinnitus, or aural pressure 1, 3
• You have none of the required auditory symptoms for Ménière's disease 1
• Canalith repositioning maneuvers achieve 78.6-93.3% success rates for BPPV versus only 30.8% improvement with medication alone 1, 2

The Correct Treatment: Canalith Repositioning Maneuvers

You need the Epley maneuver (canalith repositioning procedure), which is the definitive treatment for BPPV with success rates of 78.6-93.3%. 1, 2

Immediate Steps:

1. Stop betahistine today—it provides no benefit for BPPV and may delay proper treatment 1, 3, 2

2. See an ENT specialist or vestibular therapist within 48-72 hours for Dix-Hallpike testing to confirm posterior canal BPPV (90% of cases) 1, 2

3. Undergo Epley maneuver if Dix-Hallpike is positive—this can be performed in-office and often provides immediate relief 1, 2

4. If symptoms persist after initial maneuver, repeat Dix-Hallpike testing and additional repositioning can achieve 90-98% success rates 2

For Severe Nausea During Acute Episodes Only:

• Prochlorperazine 5-10 mg can be used for severe nausea/vomiting during acute vertigo episodes, maximum 3 doses per 24 hours 3, 4
• Use this only as needed during severe attacks, not scheduled, as vestibular suppressants interfere with compensation 1, 4
• Discontinue once the Epley maneuver resolves your BPPV 1, 4

What to Avoid

Do not continue betahistine or start other vestibular suppressants as primary treatment:

• Antihistamines like meclizine are not recommended for BPPV except for short-term nausea control 1, 4
• Benzodiazepines should be avoided as they increase fall risk and interfere with vestibular compensation 1, 4
• These medications have significant side effects including drowsiness, cognitive deficits, and increased fall risk, especially problematic given your work as a personal trainer 1, 4

Follow-Up and Reassessment

You should be reassessed within 1 month after canalith repositioning to confirm symptom resolution. 1

• If symptoms persist after proper repositioning maneuvers, this suggests either incorrect diagnosis or incomplete treatment 1, 2
• Failure to respond to repositioning maneuvers occurs in only 1.1-3% of cases and may indicate a more serious CNS disorder requiring imaging 1
• Given your head trauma history, persistent symptoms after proper BPPV treatment would warrant MRI to rule out central causes 1

Why the ER Missed This

The ER appropriately ruled out serious causes (stroke, cardiac issues) but likely did not perform Dix-Hallpike testing, which is the only way to diagnose BPPV definitively 1, 2. The prescription of betahistine suggests they may have assumed Ménière's disease without confirming the required auditory symptoms 1, 3.

Critical Point About Your Missed Dose

The fact that your vertigo returned the night you missed betahistine does not mean the medication is working—this was coincidental timing with a new BPPV episode triggered by positional changes during sleep. 1, 2 BPPV episodes are inherently episodic and position-dependent, not medication-dependent 1.