What is the most likely diagnosis and appropriate acute and preventive treatment for a 34‑year‑old woman with positional dizziness, nausea, transient visual scintillations, normal neurologic exam, prior iron‑deficiency anemia, and a partially positive canalith‑repositioning (Epley) maneuver?

Diagnosis: Benign Paroxysmal Positional Vertigo (BPPV)

This 34-year-old woman with positional dizziness, nausea, transient visual scintillations, and a partially positive Epley maneuver most likely has BPPV, and you should immediately complete the canalith repositioning procedure (Epley maneuver) as first-line treatment. 1

Diagnostic Reasoning

Why BPPV is the Primary Diagnosis

• Positional trigger: Her dizziness occurs specifically with movement and lying down, which is the hallmark of BPPV—brief episodes (<1 minute) triggered by specific head position changes 1, 2
• Partially positive Epley maneuver: You observed "slightly stagnos" (presumably nystagmus) during the repositioning attempt, which confirms the diagnosis 1
• Normal neurologic exam: No focal deficits, cranial nerves intact, no muscle weakness—all consistent with peripheral rather than central vertigo 1
• Age and demographics: BPPV is the most common cause of peripheral vertigo, accounting for 42% of cases in general practice 1

The Visual "Yellow Spots" Explained

The transient visual scintillations (yellow spots) raise the possibility of concurrent vestibular migraine, which is extremely common and often coexists with BPPV 1, 3:

• Vestibular migraine affects 3.2% of the population and accounts for 14% of all vertigo cases 1
• Visual auras (scintillations, spots) are characteristic migraine features that can occur before, during, or after vestibular symptoms 3, 4
• Critical distinction: Vestibular migraine episodes last minutes to hours, whereas BPPV episodes last seconds to <1 minute 1, 2
• Her brief positional symptoms fit BPPV; the visual phenomena suggest migraine as a comorbidity 3

Why This is NOT a Central Cause

You must actively exclude stroke, but the evidence strongly argues against it:

• No red flags present: No severe postural instability with falling, no new severe headache, no focal neurologic deficits, no downbeating or purely vertical nystagmus 1
• **Age <50 with no documented vascular risk factors**: Posterior circulation stroke accounts for 25% of acute vestibular syndrome overall but rises to 75% only in high-risk cohorts (age >50, hypertension, diabetes, atrial fibrillation, prior stroke) 2, 5
• Normal cranial nerve exam and no dysarthria/dysmetria/dysphagia: Central vertigo is frequently accompanied by these neurologic symptoms 1

Immediate Management

Step 1: Complete the Canalith Repositioning Procedure

Perform the Epley maneuver immediately 1, 2:

• Success rate is 80% after 1–3 treatments 1
• If initial treatment fails, repeat maneuvers achieve 90–98% success 1
• Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV—they prevent central compensation and do not address the mechanical pathology 1, 2

Step 2: Confirm the Diagnosis with Proper Technique

If you did not already perform a complete Dix-Hallpike maneuver bilaterally, do so now 1, 2:

• Positive findings: 5–20 second latency, torsional upbeating nystagmus toward the affected ear, symptoms resolve within 60 seconds, fatigability with repeat testing 1
• If Dix-Hallpike is negative, perform the supine roll test to detect lateral-canal BPPV (10–15% of cases) 1

Step 3: Address the Nausea

• Metoclopramide 10 mg IV or prochlorperazine 10 mg IV for acute nausea/vomiting 2
• These agents provide antiemetic relief and synergistic analgesia if headache is present 2
• Encourage oral hydration once nausea improves; her reduced intake is likely secondary to nausea 2

Step 4: Evaluate for Vestibular Migraine

Given the visual scintillations, assess for migraine features 1, 3:

• Ask about: Current or past migraine history, family history of migraine, photophobia, phonophobia during at least 50% of vertigo episodes 1
• Diagnostic criteria for vestibular migraine: ≥5 episodes of vestibular symptoms, current or history of migraine, and migraine symptoms during at least two vertiginous episodes 1, 3
• If she meets criteria, consider migraine prophylaxis (topiramate, beta-blockers, or antidepressants) and lifestyle modifications (trigger avoidance, sleep hygiene) 3, 6

What You Can Give Her

Acute Treatment (Today)

1. Complete the Epley maneuver (therapeutic, not just diagnostic) 1
2. Metoclopramide 10 mg IV or prochlorperazine 10 mg IV for nausea 2
3. Reassurance and counseling: Explain BPPV is benign, highly treatable, and not a stroke 1

Do NOT Give

• No vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV 1, 2
• No imaging (CT or MRI) unless red flags emerge 7, 1, 2

If Vestibular Migraine is Confirmed

• Acute migraine treatment: Naproxen 500–550 mg + sumatriptan 50–100 mg orally (if not pregnant/breastfeeding) 2
• Prophylaxis: Topiramate 50–100 mg daily, beta-blockers, or tricyclic antidepressants 3, 6

Follow-Up Plan

• Reassess within 1 month to document resolution or persistence 1, 2
• If symptoms persist after 2–3 repositioning attempts, refer for vestibular rehabilitation therapy 1, 2
• Counsel on recurrence risk (BPPV recurs in many patients) and fall risk (dizziness increases fall risk 12-fold in elderly, though she is young) 1

Address the Iron Deficiency

Her known iron-deficiency anemia is unlikely to cause positional vertigo but may contribute to general fatigue or lightheadedness 2:

• Check hemoglobin and ferritin if not recently done
• Replete iron stores with oral ferrous sulfate or IV iron if indicated
• Anemia does not explain the positional trigger or nystagmus, so treat BPPV first 2

Red Flags That Would Change Management

Obtain urgent MRI brain without contrast if any of the following develop 7, 1, 2:

• Severe postural instability with falling
• New severe headache
• Focal neurologic deficits (weakness, numbness, dysarthria, dysphagia)
• Downbeating or purely vertical nystagmus without torsional component
• Failure to respond to appropriate repositioning therapy
• Baseline nystagmus without provocative maneuvers (though this could indicate vestibular neuritis)

Common Pitfalls to Avoid

• Do not assume visual symptoms mean stroke: Visual auras are classic migraine features and do not mandate imaging in the absence of other red flags 1, 3
• Do not rely on patient descriptions of "dizziness": Focus on timing (seconds vs. minutes vs. hours) and triggers (positional vs. spontaneous) 7, 2
• Do not order imaging for typical BPPV: Neuroimaging has <1% diagnostic yield in isolated dizziness and is not indicated with a positive Dix-Hallpike and no red flags 7, 1, 2
• Do not prescribe vestibular suppressants for BPPV: They delay recovery and do not address the underlying mechanical problem 1, 2