What is the appropriate treatment for vertigo based on the likely underlying cause (e.g., BPPV, vestibular neuritis, Meniere's disease)?

Treatment of Vertigo Based on Underlying Cause

For vertigo, immediately perform the Dix-Hallpike maneuver to diagnose BPPV—the most common cause at 42% of cases—and treat positive findings on the spot with the Epley maneuver, which achieves 80% resolution after 1-3 treatments and 90-98% with repeat procedures. 1, 2

Immediate Diagnostic Approach

Classify vertigo by timing and triggers, not by patient descriptions of "spinning" or "dizziness": 2, 3

• Brief episodes (<1 minute) triggered by head position changes → BPPV 2, 4
• Acute persistent vertigo (days to weeks) → Vestibular neuritis, labyrinthitis, or posterior circulation stroke 2, 3
• Spontaneous episodes (20 minutes to 12 hours) with hearing loss, tinnitus, aural fullness → Ménière's disease 2, 4
• Episodes (minutes to hours) with migraine features (headache, photophobia, phonophobia) → Vestibular migraine 2, 4

Treatment by Diagnosis

Benign Paroxysmal Positional Vertigo (BPPV)

Perform the Epley maneuver immediately upon positive Dix-Hallpike test—do not prescribe vestibular suppressants (antihistamines, benzodiazepines) as they are ineffective for BPPV and delay central compensation. 1, 2

• Execute bilateral Dix-Hallpike maneuvers looking for: 5-20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolving within 60 seconds 2
• If posterior canal maneuvers are negative, perform supine roll test for lateral canal BPPV (10-15% of cases) 2
• Success rates: 80% after 1-3 Epley treatments; 90-98% with additional maneuvers 1, 2, 5
• Reassess within 1 month to confirm resolution 1
• Do not order imaging or vestibular testing for typical BPPV with positive Dix-Hallpike and no red flags 1, 2

Common pitfall: Prescribing meclizine or diazepam for BPPV—these medications have no evidence of efficacy as primary treatment and interfere with central compensation 1

Vestibular Neuritis

Treat acute phase (first 12-36 hours) with vestibular suppressants only, then immediately transition to vestibular rehabilitation therapy to promote central compensation. 6, 7

• Acute symptom control (first 1-3 days only):
  • Diazepam 10 mg IM once or twice daily for severe vertigo 7
  • Metoclopramide 10 mg IM or prochlorperazine for nausea/vomiting 7
• Early corticosteroids improve peripheral recovery: Achieve 62% labyrinthine function restoration within 12 months 6
• Vestibular rehabilitation therapy is the primary intervention after acute phase—significantly improves gait stability and accelerates central compensation 2, 6
• Symptoms: Acute onset rotatory vertigo lasting 12-36 hours, horizontal spontaneous nystagmus toward unaffected ear, pathologic head-impulse test, no hearing loss 6, 8

Critical distinction: Vestibular neuritis causes a single prolonged episode (days), whereas BPPV causes brief recurrent episodes (seconds) 2, 8

Ménière's Disease

Initiate dietary sodium restriction and diuretics as first-line therapy; reserve intratympanic gentamicin or endolymphatic sac surgery for refractory cases. 2, 5

• Diagnostic criteria: At least two spontaneous vertigo episodes lasting 20 minutes to 12 hours, fluctuating low-to-mid frequency sensorineural hearing loss, fluctuating tinnitus and aural fullness 2, 4
• Medical management:
  • Salt restriction (< 2 grams sodium daily) 2, 5
  • Diuretics (limited evidence but widely used) 2
  • Oral corticosteroids for acute attacks 2
• Refractory disease:
  • Intratympanic gentamicin for persistent vertigo despite medical therapy 2
  • Endolymphatic sac decompression surgery when medical/intratympanic treatments fail 2
• Obtain comprehensive audiometry to document characteristic fluctuating hearing pattern 2

Key distinguishing feature: Fluctuating hearing loss in Ménière's versus stable/absent hearing loss in vestibular migraine 2, 4

Vestibular Migraine

Treat with migraine prophylaxis (not vestibular suppressants) and lifestyle modifications; use naproxen 500-550 mg plus sumatriptan 50-100 mg for acute attacks. 2, 3

• Diagnostic criteria: Episodic vestibular symptoms with migraine by International Headache Society criteria, plus at least two migraine symptoms (headache, photophobia, phonophobia, visual aura) during at least two vertiginous episodes 2
• Episodes last 5 minutes to 72 hours 2
• Lifetime prevalence 3.2%; accounts for 14% of all vertigo cases but is extremely under-recognized 2, 4
• Acute treatment: Naproxen-triptan combination initiated promptly after onset 3
• Prophylaxis: Standard migraine preventive medications and trigger avoidance 2
• Motion intolerance and light sensitivity are characteristic triggers 2

Common pitfall: Missing vestibular migraine diagnosis in young patients with recurrent vertigo—always ask about migraine history, family history, photophobia, and phonophobia 2

Red Flags Requiring Immediate MRI and Neurologic Consultation

Any of the following mandate urgent diffusion-weighted MRI to exclude posterior circulation stroke: 2, 3

• Severe postural instability with falling 2
• New-onset severe headache with vertigo 2, 3
• Focal neurological deficits (dysarthria, dysmetria, dysphagia, limb weakness, diplopia, Horner's syndrome) 2, 4
• Downbeating or purely vertical nystagmus without torsional component 2
• Direction-changing nystagmus without head position changes 2
• Baseline nystagmus present without provocative maneuvers 2
• Nystagmus that does not fatigue with repeated testing and is not suppressed by visual fixation 2
• Sudden unilateral hearing loss 2, 3
• Failure to respond to appropriate peripheral vertigo treatments 2

Critical epidemiology: 25% of acute vestibular syndrome presentations have cerebrovascular disease, rising to 75% in high vascular risk patients (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) 2, 3, 4

Diagnostic imaging: MRI with diffusion-weighted imaging has 4% diagnostic yield versus <1% for CT head; CT misses most posterior circulation infarcts with only 10-20% sensitivity 2, 3

Special Populations

Elderly Patients

• BPPV is present in 9% of elderly patients referred for geriatric evaluation; three-fourths had fallen within prior 3 months 2
• Dizziness increases fall risk 12-fold in elderly patients 2
• Counsel on fall prevention, home safety assessment, and need for supervision if frail 2
• Vestibular rehabilitation therapy is particularly beneficial for elderly patients with heightened fall risk 2

High Vascular Risk Patients

• Obtain MRI brain without contrast even with normal neurologic examination if age >50 with hypertension, diabetes, atrial fibrillation, or prior stroke—11-25% harbor posterior circulation stroke 2, 3
• Vertebrobasilar insufficiency episodes last <30 minutes without hearing loss and may precede stroke by weeks to months 2, 4

What NOT to Do

• Do not prescribe vestibular suppressants for BPPV—no evidence of efficacy and they interfere with compensation 1
• Do not order CT head for isolated vertigo—diagnostic yield <1% and misses posterior circulation infarcts 2, 3
• Do not order imaging for typical BPPV with positive Dix-Hallpike and no red flags 1, 2
• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus on timing, triggers, and associated symptoms 2, 3
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes presenting with acute vestibular syndrome lack focal deficits 2, 3