How should peripheral vertigo be managed?

Treatment of Peripheral Vertigo

Canalith repositioning procedures (CRPs), specifically the Epley maneuver for posterior canal BPPV, are the definitive first-line treatment for peripheral vertigo, with success rates of 80-90% after 1-3 treatments and 90-98% with repeat maneuvers if needed. 1

Immediate Treatment Algorithm

Step 1: Identify the Affected Canal

• Perform the Dix-Hallpike test for posterior canal BPPV (accounts for 85-95% of cases), looking for torsional upbeating nystagmus 1
• If Dix-Hallpike is negative but BPPV suspected, perform the supine roll test to assess for lateral (horizontal) canal BPPV (10-15% of cases) 1
• Observe for geotropic (direction-changing toward ground) or apogeotropic (direction-changing away from ground) nystagmus patterns 1

Step 2: Execute the Appropriate Repositioning Maneuver

For Posterior Canal BPPV (most common):

• Epley Maneuver: Patient sits upright with head turned 45° toward affected ear, rapidly lay back to supine head-hanging 20° position for 20-30 seconds, turn head 90° toward unaffected side, roll patient onto shoulder while maintaining head position, then return to sitting 1, 2
• Alternative: Semont Maneuver with 94.2% resolution at 6 months 1
• Success rate: 80.5% negative Dix-Hallpike by day 7 1

For Horizontal Canal BPPV:

• Geotropic variant: Barbecue Roll (Lempert) Maneuver with 50-100% success rate, or Gufoni Maneuver with 93% success rate 1
• Apogeotropic variant: Modified Gufoni Maneuver (patient lies on affected side) 1

Step 3: Post-Treatment Instructions

• No postprocedural restrictions are necessary - patients can resume normal activities immediately 1
• This is critical: postprocedural restrictions provide no benefit and may cause unnecessary complications 1

Medication Management: What NOT to Do

Do NOT routinely prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) for BPPV treatment. 1

Why Medications Should Be Avoided:

• No evidence of effectiveness as definitive treatment for BPPV 1
• Cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk (especially in elderly) 1
• Interfere with central compensation mechanisms in peripheral vestibular conditions 1
• Decrease diagnostic sensitivity during Dix-Hallpike maneuvers 1

Limited Exception:

• Vestibular suppressants may be considered only for short-term management of severe nausea/vomiting in severely symptomatic patients 1
• Meclizine FDA-approved dosing: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 3

Treatment Failure Protocol: Reassess Within 1 Month

If symptoms persist after initial treatment, reassess within 1 month to identify treatment failures. 4, 1

Systematic Reevaluation Steps:

1. Repeat the diagnostic test (Dix-Hallpike or supine roll test) to confirm persistent BPPV 1, 5

   • If positive: Repeat CRP achieves 90-98% success rates 4, 1

2. Check for canal conversion (occurs in 6-7% of cases) 1

   • Posterior canal may convert to lateral canal or vice versa 1
   • Perform supine roll test if Dix-Hallpike now negative 1

3. Evaluate for multiple canal involvement 1, 5

   • Test all canals systematically 5

4. Screen for central nervous system disorders if atypical features present 4, 5:

   • Red flags requiring urgent evaluation: Nystagmus that changes direction without head position changes, downward nystagmus in Dix-Hallpike, spontaneous nystagmus without provocation 5
   • Lack of response after 2-3 repositioning attempts 5
   • Associated neurological symptoms (abnormal cranial nerves, severe headache, visual disturbances) 5
   • Approximately 3% of BPPV treatment failures have underlying CNS disorder 5

Adjunctive Vestibular Rehabilitation Therapy

Offer VRT as adjunctive therapy (not as substitute for CRP), particularly for patients with residual dizziness, postural instability, or heightened fall risk after successful CRP. 1

When to Add VRT:

• After successful CRP to reduce recurrence rates by approximately 50% 1
• For persistent mild residual symptoms lasting days to weeks after successful treatment 1
• Patients with gait instability show significantly improved stability with CRP plus VR exercises compared to CRP alone 1

VRT Components:

• Habituation exercises for symptom provocation 1
• Adaptation exercises for gaze stabilization 1
• Compensation exercises for vestibular deficits 1

Note: Brandt-Daroff exercises are less effective than CRP (24% vs 71-74% success rate at 1 week) and should not be first-line 1

Self-Treatment Option for Motivated Patients

Self-administered CRP can be taught after at least one properly performed in-office treatment, with 64% improvement rate compared to 23% with self-administered Brandt-Daroff exercises. 1

Special Populations Requiring Modified Approach

Assess all patients before treatment for contraindications: 1

• Severe cervical stenosis or radiculopathy 1
• Severe rheumatoid arthritis or ankylosing spondylitis 1
• Morbid obesity 1
• Severe kyphoscoliosis or limited cervical range of motion 1
• Known cerebrovascular disease 1

For patients with contraindications: Consider Brandt-Daroff exercises or refer to specialized vestibular physical therapy 1

Critical Safety Considerations

Elderly patients with BPPV are at 12-fold increased fall risk. 1

• 9% of patients referred to geriatric clinics have undiagnosed BPPV 1
• Three-quarters of elderly BPPV patients have fallen within previous 3 months 1
• Counsel regarding home safety assessment, activity restrictions, and need for supervision 1

Common Pitfalls to Avoid

• Not performing maneuvers immediately upon diagnosis - CRP should be performed at the initial visit without delay for medications or imaging 1
• Ordering unnecessary imaging - do not obtain MRI or vestibular testing unless atypical neurological signs present 1
• Prescribing vestibular suppressants routinely - these interfere with compensation and delay recovery 1, 6
• Imposing postprocedural restrictions - strong evidence shows no benefit 1
• Missing the 1-month reassessment window - allows identification of persistent BPPV or missed diagnoses 4, 1
• Assuming initial diagnosis was correct in treatment failures - approximately 3% have missed CNS disorders 5

Vestibular Neuronitis (Non-BPPV Peripheral Vertigo)

For acute vestibular neuronitis, avoid prolonged vestibular suppressants as they interfere with central compensation mechanisms. 6

• Antiemetics may be used briefly for severe nausea/vomiting during acute phase only 6
• Discontinue as soon as tolerable to avoid delaying central compensation 6
• Recovery occurs through central compensation, enhanced by early mobilization 6
• Patients with cardiovascular risk factors presenting with acute vestibular syndrome require evaluation for posterior circulation stroke (4% of isolated dizziness cases are stroke) 6