What is the management of sudden vertigo?

Management of Sudden Vertigo

The immediate priority in managing sudden vertigo is to perform the Dix-Hallpike maneuver bilaterally to diagnose or exclude BPPV, and if positive, treat immediately with the Epley maneuver, which achieves 80-93% success rates after 1-3 treatments; however, you must first rule out central causes by assessing for red-flag features including severe postural instability with falling, new-onset severe headache, focal neurologic deficits, or pure vertical nystagmus without torsional component—any of which mandate urgent MRI with diffusion-weighted imaging. 1, 2, 3

Initial Clinical Assessment: Distinguish Central from Peripheral Causes

The first critical decision point is determining whether the vertigo originates from a peripheral vestibular disorder (benign and treatable at bedside) or a central lesion (potentially life-threatening). 1, 3

Red Flags Requiring Immediate MRI with Diffusion-Weighted Imaging

Stop and order urgent neuroimaging if any of the following are present: 1, 3

• Severe postural instability with actual falling during gait testing (not just subjective imbalance) 1, 3
• New-onset severe headache concurrent with vertigo 1
• Any focal neurologic symptoms: dysarthria, dysmetria, dysphagia, limb weakness, sensory deficits, diplopia, or Horner's syndrome 1
• Pure vertical nystagmus (upbeating or downbeating) without any torsional component 1, 3
• Downbeating nystagmus on Dix-Hallpike without torsional rotation 1
• Baseline nystagmus present without any provocative maneuvers 1
• Direction-changing nystagmus that switches without changes in head position 1
• Nystagmus that does not fatigue with repeated testing 1
• Nystagmus not suppressed by visual fixation 1
• Gaze-evoked nystagmus (direction changes with eccentric gaze) 1

Critical pitfall: Approximately 75-80% of patients with posterior circulation stroke present without focal neurologic deficits, making stroke easy to miss. 3 In high vascular-risk populations, up to 75% of acute vestibular syndrome cases are due to stroke. 3 CT head has less than 1% diagnostic yield for isolated dizziness and frequently misses posterior circulation strokes. 1, 3

Diagnostic Maneuvers: Perform Immediately

Dix-Hallpike Maneuver (for Posterior Canal BPPV)

Execute bilaterally by moving the patient from upright to supine, turning the head 45° to the side being tested and extending the neck approximately 20°. 1, 2

Positive result indicating peripheral BPPV: 1, 2

• Torsional and upbeating nystagmus
• Latency of 5-20 seconds before onset
• Crescendo-decrescendo pattern
• Resolves within 60 seconds
• Fatigues with repeated testing

Findings suggesting central pathology: 1, 2

• Immediate onset without latency
• Persistent nystagmus that does not resolve
• Purely vertical nystagmus without torsional component
• Does not fatigue with repeat testing

Supine Roll Test (for Lateral Canal BPPV)

With the patient supine, rapidly turn the head 90° to each side. 1

Positive result: Horizontal nystagmus accompanied by vertigo 1

Treatment Algorithm Based on Diagnosis

If Dix-Hallpike is Positive for BPPV

Perform the Epley maneuver (canalith repositioning procedure) immediately upon diagnosis. 2 This achieves 80-93% success after 1-3 treatments and 90-98% with additional maneuvers if initial treatment fails. 2

Do NOT prescribe vestibular suppressant medications for BPPV. 2 Repositioning maneuvers have 78.6-93.3% efficacy compared to only 30.8% for medications, and vestibular suppressants prevent central compensation. 2 Meclizine may only be considered for severe nausea/vomiting during the maneuver itself or in patients who refuse repositioning, used for maximum 3-5 days. 2

Do NOT order postprocedural postural restrictions. 2

Do NOT order neuroimaging if Dix-Hallpike is positive with typical nystagmus and no red-flag features are present. 1, 2

If Acute Vestibular Neuronitis/Labyrinthitis is Suspected

This presents as acute onset of severe continuous vertigo lasting days to weeks with nausea, vomiting, and intolerance to head motion, without hearing loss (neuronitis) or with hearing loss (labyrinthitis). 1

Treatment: 2, 4

• Short-term vestibular suppressants for symptomatic relief only (meclizine 25-100 mg daily in divided doses for maximum 3-5 days) 2, 4
• Initiate vestibular rehabilitation exercises early 2

Caution with vestibular suppressants: Significant adverse effects in elderly patients including drowsiness, cognitive deficits, anticholinergic effects, and increased fall risk. 2 Contraindicated in patients with asthma, glaucoma, or prostate enlargement. 2

If Ménière's Disease is Suspected

Characterized by episodic vertigo lasting hours, fluctuating sensorineural hearing loss, tinnitus, and aural fullness. 1

First-line preventive therapy: 2

• Dietary sodium restriction (1500-2300 mg daily) 2
• Diuretics 2
• Limit alcohol and caffeine intake 2

Acute attack management: 2

• Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) for maximum 3-5 days 2
• Betahistine may be considered to increase inner ear vasodilation 2

If Vestibular Migraine is Suspected

Episodes can be short (<15 minutes) or prolonged (>24 hours), with visual auras, motion intolerance, and light sensitivity as triggers. 1 Hearing loss is typically mild, absent, or stable over time—not fluctuating like Ménière's disease. 1

Key distinguishing feature: Stable or absent hearing loss (vestibular migraine) versus fluctuating hearing loss that worsens over time (Ménière's disease). 1

If Vertebrobasilar Insufficiency is Suspected

Episodes typically last less than 30 minutes without hearing loss, with severe postural instability and gaze-evoked nystagmus. 1 Critical warning: Isolated transient vertigo may precede vertebrobasilar stroke by weeks to months. 1 This requires urgent neuroimaging and vascular evaluation. 3

Follow-Up and Reassessment

Reassess all patients within 1 month after initial treatment to document resolution or persistence of symptoms. 2 If symptoms persist, repeat the Dix-Hallpike test to confirm ongoing BPPV or identify other vestibular pathology. 2

Indications for vestibular rehabilitation: 2

• Persistent dizziness from any vestibular cause
• Chronic imbalance
• Incomplete recovery after initial treatment
• Can be self-administered or therapist-directed

Counsel all patients on: 2

• Fall risk, particularly in elderly patients (12-fold increased risk) 3
• Potential recurrence of BPPV 2
• Importance of follow-up 2

Common Pitfalls to Avoid

• Do not assume BPPV without performing diagnostic maneuvers—the symptom description alone is insufficient. 1
• Do not rely on absence of focal neurologic deficits to rule out stroke—up to 80% of stroke-related acute vestibular syndrome presents without focal findings. 3
• Do not order CT head for isolated vertigo—diagnostic yield is less than 1% and it frequently misses posterior circulation strokes. 1, 3
• Do not prescribe vestibular suppressants as primary treatment for BPPV—they are significantly less effective than repositioning maneuvers and prevent central compensation. 2
• Do not overlook the possibility of multiple concurrent vestibular disorders (e.g., BPPV with Ménière's disease or vestibular neuritis). 1
• Do not miss cerebellar infarction—approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders. 1