What is the appropriate management and diagnosis for a patient experiencing vertigo (dizziness) towards the left side, nausea, and loss of balance?

Management of Left-Sided Vertigo with Nausea and Loss of Balance

Perform the Dix-Hallpike maneuver immediately to diagnose benign paroxysmal positional vertigo (BPPV), which is the most common cause of positional vertigo and can be definitively treated with the Epley maneuver in the same visit. 1

Initial Diagnostic Approach

Classify the vertigo by timing and triggers rather than relying on the patient's subjective description of "dizziness." 2, 3 The key questions to ask are:

• Duration of episodes: Seconds (<1 minute) suggests BPPV, minutes to hours suggests vestibular migraine or Ménière's disease, days to weeks suggests vestibular neuritis or stroke 2, 3
• Triggers: Specific head position changes (rolling over in bed, looking up, bending forward) strongly suggest BPPV 1
• Associated symptoms: Hearing loss, tinnitus, or aural fullness suggest Ménière's disease; headache with photophobia/phonophobia suggests vestibular migraine 1, 2

Physical Examination Protocol

Execute the Dix-Hallpike maneuver bilaterally to identify which ear is affected: 1

• Position the patient so their head can hang 20 degrees off the examination table edge 1
• Rotate the head 45 degrees toward the left side, then rapidly move the patient from sitting to supine with head extended 1
• Observe for characteristic findings: 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms that crescendo then resolve within 60 seconds 1
• Repeat for the right side 1

Perform a focused neurologic examination looking specifically for red flags: 2, 3

• Focal deficits (dysarthria, dysmetria, dysphagia, sensory/motor loss, Horner's syndrome) 2
• Downbeating nystagmus without torsional component 2
• Direction-changing nystagmus without head position changes 2
• Inability to stand or walk 2, 3

When Imaging Is NOT Needed

Do not order imaging if the patient has: 3

• Positive Dix-Hallpike test consistent with BPPV 3
• Normal neurologic examination 3
• No red flag symptoms 3
• Brief episodic symptoms triggered by position changes 3

When Imaging IS Required

Order MRI brain without contrast immediately if any of the following are present: 2, 3

• Abnormal neurologic examination findings 3
• High vascular risk factors (age >50, hypertension, diabetes, prior stroke, atrial fibrillation) even with normal exam 2, 3
• Sudden unilateral hearing loss 2, 3
• New severe headache accompanying vertigo 2, 3
• Downbeating or direction-changing nystagmus 2
• Inability to stand or walk 2

Critical pitfall: 75-80% of patients with posterior circulation stroke from acute vestibular syndrome have no focal neurologic deficits, making stroke easy to miss. 2 CT head has extremely low yield (<1%) and misses most posterior circulation infarcts. 2, 3

Treatment Based on Diagnosis

If BPPV is Confirmed (Positive Dix-Hallpike)

Perform the Epley maneuver (canalith repositioning procedure) immediately: 1, 4

• Success rate is 80% after 1-3 treatments 1
• Success rate increases to 90-98% with repeat maneuvers if initial treatment fails 1
• No medications are needed for typical BPPV 1
• Meclizine may be used only for immediate symptom relief during acute episodes but does not treat the underlying condition 5

Counsel the patient about: 1

• Recurrence risk (BPPV commonly recurs) 1
• Fall risk, especially if elderly (dizziness increases fall risk 12-fold) 2
• Home safety assessment 2
• Return promptly if symptoms recur for repeat repositioning 1

If Vestibular Neuritis is Suspected

Acute persistent vertigo lasting days with unidirectional horizontal nystagmus: 2

• Vestibular suppressants (meclizine, diazepam) for acute symptom relief only 4, 6
• Vestibular rehabilitation therapy is the primary treatment and significantly improves gait stability compared to medication alone 1, 4
• Avoid prolonged use of vestibular suppressants as they delay central compensation 4

If Central Cause Cannot Be Excluded

Admit for observation and obtain urgent MRI with diffusion-weighted imaging if: 2, 7

• High vascular risk with acute vestibular syndrome 2
• Any red flag symptoms present 2
• HINTS examination suggests central cause (normal head impulse test, direction-changing nystagmus, skew deviation present) 2, 3

Follow-Up

Reassess within one month after initial treatment to: 1

• Document resolution or persistence of symptoms 1
• Educate about atypical symptoms (subjective hearing loss, gait disturbance, non-positional vertigo, persistent nausea/vomiting) that warrant further evaluation 1
• Consider vestibular rehabilitation if balance issues persist despite successful repositioning 1

Common pitfall: Approximately 50% of BPPV patients report subjective imbalance between classic episodes, which is normal and does not indicate treatment failure. 1