What is the recommended management for an adult with acute episodic vertigo and no red‑flag features, considering possible benign paroxysmal positional vertigo, vestibular neuritis, or Meniere’s disease?

Management of Acute Episodic Vertigo Without Red Flags

Perform the Dix-Hallpike maneuver immediately at presentation, and if positive for BPPV, execute the Epley maneuver in the same visit—this single intervention achieves 80% resolution after 1-3 treatments and should never be delayed for imaging or vestibular suppressant medications. 1

Immediate Bedside Diagnostic Approach

Step 1: Perform Dix-Hallpike Maneuver Bilaterally

Execute this test on both sides to diagnose or exclude benign paroxysmal positional vertigo (BPPV), which accounts for 42% of all vertigo cases in general practice. 1

Positive BPPV findings include:

• Torsional and upbeating nystagmus with 5-20 second latency 1
• Crescendo-decrescendo pattern 1
• Fatigues with repeat testing 1
• Resolves within 60 seconds 1

Red-flag findings demanding immediate MRI:

• Pure vertical (up or down) nystagmus without torsional component 1
• Immediate onset without latency 1
• Persistent nystagmus that does not fatigue 1
• Baseline nystagmus present without provocative maneuvers 1

Step 2: Characterize Episode Duration and Triggers

Episode duration distinguishes the three main diagnoses:

• BPPV: Episodes last <1 minute, triggered by specific head position changes relative to gravity 1
• Vestibular neuritis: Continuous vertigo lasting days to weeks with nausea, vomiting, and intolerance to head motion 1
• Menière's disease: Episodes last hours, with fluctuating hearing loss, tinnitus, and aural fullness 1

Step 3: Assess for Hearing Loss

Perform Weber and Rinne tests; an abnormal Weber test mandates formal audiometry to differentiate conductive from sensorineural loss. 1

Hearing loss patterns:

• Fluctuating sensorineural hearing loss that worsens over time = Menière's disease 1
• Stable or absent hearing loss = BPPV or vestibular neuritis 1
• Hearing loss with vertigo = labyrinthitis (not vestibular neuritis) 1

Treatment by Diagnosis

BPPV (Positive Dix-Hallpike)

Perform the Epley maneuver immediately upon diagnosis—do not delay. 1

• Success rate: 80% after 1-3 treatments, 90-98% with additional maneuvers if initial treatment fails 1
• Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate) for BPPV—they prevent central compensation and have no role in canalith repositioning 1
• Do NOT impose postprocedural postural restrictions—they do not improve outcomes 1
• Reassess within 1 month; if symptoms persist, repeat Dix-Hallpike and perform additional repositioning maneuvers 2, 1

Common pitfall: Up to 6% of patients experience "canal conversion" (posterior canal BPPV transforms to lateral canal BPPV or vice versa), so reassessment must include testing for all canal variants. 2

Vestibular Neuritis (Acute Continuous Vertigo Without Hearing Loss)

Use vestibular suppressants only for the first 2-3 days, then discontinue to allow central compensation. 3, 4

• Meclizine 25-100 mg daily in divided doses for acute symptom relief 5
• Warn patients about drowsiness and avoid alcohol 5
• Begin vestibular rehabilitation physical therapy immediately after the acute phase (after stopping suppressants) to promote compensation 3, 4
• Vestibular neuritis accounts for 41% of peripheral vertigo cases 1

Evidence note: Some studies suggest corticosteroids may improve recovery, but more high-quality trials are needed to prove efficacy. 6

Menière's Disease (Episodic Vertigo + Fluctuating Hearing Loss + Tinnitus + Aural Fullness)

Initiate dietary sodium restriction (<1500-2000 mg/day) and diuretics as first-line prophylaxis. 1, 4

• Betahistine (not FDA-approved in the U.S.) at high doses long-term is effective by increasing inner-ear blood flow 6
• Vestibular suppressants (meclizine) for acute attacks only 3
• Vestibular rehabilitation for chronic disequilibrium 1
• Accounts for 10% of vertigo in general practice, up to 43% in specialty settings 1

Critical pitfall: Menière's disease frequently coexists with BPPV—perform Dix-Hallpike even when Menière's is suspected, as treating concurrent BPPV significantly improves outcomes. 1

When to Order Imaging (MRI Brain with Diffusion-Weighted Imaging)

Obtain urgent MRI if ANY of the following red flags are present:

• Severe postural instability with falling 1
• New-onset severe headache with vertigo 1
• Any additional neurologic symptoms (dysarthria, dysmetria, dysphagia, diplopia, limb weakness, sensory deficits, Horner's syndrome) 1
• Downbeating nystagmus on Dix-Hallpike without torsional component 1
• Pure vertical nystagmus without torsional component 1
• Direction-changing nystagmus without head position changes 1
• Nystagmus not suppressed by visual fixation 1
• Failure to respond to appropriate peripheral vertigo treatments 1

Epidemiology of central causes: Approximately 25% of acute vestibular syndrome presentations are posterior circulation strokes, rising to 75% in high-risk vascular populations, and 75-80% present without focal neurologic deficits initially. 1 Ten percent of cerebellar strokes mimic peripheral vestibular disorders. 1

When NOT to Order Testing

Do NOT obtain CT head or MRI for:

• Typical BPPV with positive Dix-Hallpike and characteristic nystagmus 1
• Isolated dizziness without red flags (CT diagnostic yield <1%, MRI 4%) 1

Do NOT order vestibular function testing (electronystagmography, caloric testing) in patients meeting diagnostic criteria for BPPV without additional vestibular signs/symptoms. 1

Medication Review

Evaluate all patients for ototoxic or vestibulotoxic medications:

• Aminoglycosides (gentamicin) cause irreversible vestibular toxicity 1
• Anticonvulsants (carbamazepine, phenytoin), antihypertensives, and cardiovascular drugs can cause vertigo 1

Follow-Up Protocol

Reassess all patients within 1 month to document resolution or persistence of symptoms. 1

If symptoms persist after initial BPPV treatment:

• Repeat Dix-Hallpike to confirm persistent BPPV 2
• Perform additional Epley maneuvers (success rate 90-98% with repeated procedures) 1
• Consider lateral canal or anterior canal BPPV variants 2
• Consider coexisting vestibular dysfunction (vestibular neuritis, Menière's disease, migraine) 2
• If still no response, obtain MRI—3% of BPPV treatment failures have CNS disorders 2

Special Considerations

Post-traumatic vertigo: Head trauma is a recognized cause of BPPV and may present with vertigo, disequilibrium, tinnitus, and headache; treat with Epley maneuver. 1

Vestibular migraine: Lifetime prevalence 3.2%, accounts for 14% of vertigo cases; episodes can be short (<15 minutes) or prolonged (>24 hours) with photophobia, phonophobia, or visual aura; hearing loss is stable or absent (not fluctuating like Menière's); consider dietary modifications and migraine prophylaxis. 1

Vertebrobasilar insufficiency: Episodes last <30 minutes without hearing loss, may precede stroke by weeks to months; characterized by severe postural instability, gaze-evoked nystagmus, and nystagmus that does not fatigue—requires urgent MRI. 1