How should I assess and initially treat a patient with vertigo, including red‑flag screening, bedside examination (e.g., Dix‑Hallpike maneuver, head‑impulse test), and first‑line therapy for benign paroxysmal positional vertigo?

Assessment and Initial Treatment of Vertigo

Perform the Dix-Hallpike maneuver immediately at the bedside to diagnose posterior canal BPPV, and if positive, treat with the Epley maneuver in the same visit—this approach achieves 80% symptom resolution without any imaging or medications. 1, 2

Red-Flag Screening (Perform FIRST)

Screen for central causes requiring urgent neuroimaging before proceeding with BPPV evaluation:

• Focal neurological deficits on examination (cranial nerve abnormalities, limb weakness, sensory loss) 1, 3
• Sudden unilateral hearing loss accompanying vertigo 1, 3
• Inability to stand or walk independently 1, 3
• New severe headache with vertigo onset 1, 3
• Downbeating nystagmus or direction-changing nystagmus without head position change 1, 3
• High vascular risk (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) with acute persistent vertigo lasting days 3, 4

If ANY red flag is present: Obtain MRI brain without contrast immediately and consult neurology—do NOT perform repositioning maneuvers until stroke is excluded. 3, 4

Bedside Examination for BPPV (If No Red Flags)

Dix-Hallpike Maneuver (Posterior Canal—85-95% of BPPV)

Technique: 1, 2

1. Seat patient upright, turn head 45° toward the side being tested
2. Rapidly lay patient back to supine with head hanging 20° below horizontal
3. Hold position for 60 seconds, observe eyes for nystagmus

Positive test criteria: 1, 2

• Latency of 5-20 seconds before symptoms begin
• Torsional, upbeating nystagmus toward the affected (dependent) ear
• Vertigo and nystagmus increase then resolve within 60 seconds

Critical point: Test BOTH sides—the positive side identifies the affected ear. 1

Supine Roll Test (Horizontal Canal—10-15% of BPPV)

Perform if Dix-Hallpike is negative but positional vertigo persists: 1, 2

1. Patient lies supine with head flat
2. Rapidly turn head 90° to one side, hold 30 seconds
3. Return to center, then rapidly turn 90° to opposite side

Positive test: Horizontal nystagmus with vertigo on either or both sides 1, 2

Head-Impulse Test (For Acute Persistent Vertigo)

Only perform if symptoms are continuous (days), not episodic (seconds): 3, 4

• Abnormal test (eyes move with head, then catch-up saccade) = peripheral vestibular neuritis
• Normal test with acute vertigo = consider posterior circulation stroke, especially if age >50 or vascular risk factors 3, 4

First-Line Therapy for Posterior Canal BPPV

Epley Maneuver (Canalith Repositioning Procedure)

Perform immediately after positive Dix-Hallpike—do NOT delay for imaging or medications: 1, 2

Steps: 2

1. Start with patient seated, head turned 45° toward affected ear
2. Rapidly lay back to supine head-hanging 20° position, hold 20-30 seconds
3. Turn head 90° toward unaffected side, hold 20-30 seconds
4. Roll patient onto unaffected side (nose pointing down 45°), hold 20-30 seconds
5. Sit patient upright

Expected outcomes: 1, 2

• 80% symptom resolution after 1-3 treatments
• 90-98% success with repeat maneuvers if initial treatment fails

Post-maneuver instructions: 1, 2

• Resume normal activities immediately—postprocedural restrictions provide NO benefit
• Mild imbalance for 24 hours is common and self-limiting
• Reassess within 1 month to confirm resolution

First-Line Therapy for Horizontal Canal BPPV

If supine roll test is positive: 2

• Geotropic variant (stronger nystagmus when affected ear is down): Barbecue Roll (Lempert) maneuver—roll patient 360° in 90° increments, each position held 30 seconds 2
• Apogeotropic variant (stronger nystagmus when affected ear is up): Modified Gufoni maneuver—patient lies on affected side 30 seconds, then turn head 45° toward ground, hold 1-2 minutes 2

What NOT to Do

Do NOT order: 1

• Neuroimaging (CT or MRI) for typical BPPV with positive Dix-Hallpike and no red flags
• Vestibular function testing for straightforward BPPV
• Laboratory tests—they do not diagnose BPPV

Do NOT prescribe: 1, 2

• Meclizine, antihistamines, or benzodiazepines—no evidence of effectiveness for BPPV
• These medications interfere with central compensation and increase fall risk
• Exception: Short-term use (1-2 doses) for severe nausea/vomiting only

Treatment Failures and Reassessment

If symptoms persist after 2-3 properly performed Epley maneuvers: 1, 2

1. Repeat diagnostic test to confirm persistent BPPV (repeat Dix-Hallpike or supine roll)
2. Check for canal conversion (6-7% of cases)—posterior may convert to horizontal or vice versa 1, 2
3. Evaluate for multiple canal involvement (rare but possible) 1
4. Consider coexisting vestibular dysfunction if symptoms occur with general head movements, not just position changes 1
5. Rule out CNS disorders if atypical features present—3% of treatment failures have central pathology 1

Safety Counseling (ESSENTIAL)

BPPV increases fall risk 12-fold, especially in elderly patients: 1, 2

• Counsel on home safety assessment and activity restrictions until resolved
• Educate about recurrence risk: 10-18% at 1 year, 30-50% at 5 years 2
• Instruct to return immediately for repeat Epley if symptoms recur
• Delay between diagnosis and treatment creates high-risk period for falls 2

Common Pitfalls to Avoid

• Relying on patient's description of "spinning" vs "lightheadedness"—focus on timing (seconds = BPPV) and triggers (position changes) instead 3, 4
• Assuming normal neurologic exam excludes stroke—75-80% of posterior circulation strokes have NO focal deficits 3
• Using CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 3, 4
• Performing Dix-Hallpike too slowly—rapid movement is essential for accurate diagnosis 1
• Stopping after one negative Dix-Hallpike—must test BOTH sides 1