How should I evaluate and manage a patient presenting with vertigo, including red‑flag assessment, bedside positional testing for benign paroxysmal positional vertigo, and treatment options for BPPV, Ménière’s disease, and vestibular neuritis?

Evaluation and Management of Vertigo

Perform the Dix-Hallpike maneuver immediately in any patient presenting with vertigo, and if positive for BPPV, execute the Epley repositioning maneuver at the same visit—this single intervention achieves 80% symptom resolution and requires no imaging, laboratory testing, or medication. 1

Red-Flag Assessment: Identifying Central vs. Peripheral Causes

Before proceeding with positional testing, rapidly screen for features that mandate urgent neuroimaging:

Immediate MRI Brain (Without Contrast) Required For:

• Focal neurological deficits on examination—dysarthria, limb weakness, sensory loss, diplopia, Horner's syndrome 1, 2
• Sudden unilateral hearing loss accompanying vertigo 1
• New severe headache with vertigo onset 1
• Inability to stand or walk (severe postural instability with falling) 1, 2
• Downbeating nystagmus or purely vertical nystagmus without torsional component 1, 2
• Baseline nystagmus present without any provocative maneuvers 2
• Direction-changing nystagmus without head position changes 2
• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)—even with normal neurologic exam, because 11–25% harbor posterior circulation stroke 1

Critical Pitfall to Avoid:

75–80% of patients with posterior circulation stroke present without focal neurologic deficits, so a normal neurologic exam does NOT exclude stroke in high-risk patients 1. The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for stroke when performed by trained neuro-otology specialists, but emergency physicians achieve inadequate accuracy—therefore, obtain MRI for any high-risk patient regardless of HINTS results 1.

Bedside Positional Testing for BPPV

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

1. Patient seated upright, head turned 45° toward the side being tested
2. Rapidly lay patient back to supine with head hanging 20° off the table edge
3. Observe for 5–20 second latency, then torsional upbeating nystagmus toward the affected ear
4. Nystagmus and vertigo crescendo then resolve within 60 seconds and fatigue with repeat testing 1, 3

Positive test = BPPV confirmed; proceed immediately to Epley maneuver 3

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

If Dix-Hallpike is negative but positional vertigo persists:

1. Patient supine, head neutral
2. Rapidly turn head 90° to each side
3. Geotropic nystagmus (beating toward ground) = canalithiasis (80% of horizontal BPPV)
4. Apogeotropic nystagmus (beating away from ground) = cupulolithiasis (20% of horizontal BPPV) 3

Treatment of BPPV

Posterior Canal BPPV—Epley Maneuver:

Perform immediately upon positive Dix-Hallpike test 3:

1. From Dix-Hallpike position (head hanging 45° toward affected ear), hold 20–30 seconds
2. Turn head 90° toward unaffected side, hold 20–30 seconds
3. Roll patient onto unaffected side (nose pointing 45° downward), hold 20–30 seconds
4. Sit patient upright with head turned 45° toward unaffected shoulder

Success rate: 80% after 1–3 treatments; 90–98% with additional maneuvers if initial treatment fails 4, 3

Horizontal Canal BPPV—Geotropic Variant:

Gufoni Maneuver (93% success rate) 3:

1. From sitting, move patient to side-lying on unaffected side for 30 seconds
2. Quickly rotate head 45–60° toward ground, hold 1–2 minutes
3. Return to sitting with head turned toward unaffected shoulder

Alternative: Barbecue Roll (Lempert) Maneuver (50–100% success) 3: Roll patient 360° through prone position in 90° increments, holding each position 15–30 seconds

Horizontal Canal BPPV—Apogeotropic Variant:

Modified Gufoni Maneuver: Same as above but patient lies on affected side first 3

Critical Post-Treatment Instructions:

• No postprocedural restrictions—patients resume normal activities immediately 3
• Do NOT prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines)—they provide no benefit for BPPV and delay central compensation 3
• Reassess within 1 month to confirm resolution 4, 3
• Counsel on fall risk—BPPV increases fall risk 12-fold, especially in elderly 1, 3

Treatment Failures:

If symptoms persist after initial repositioning 4:

1. Repeat Dix-Hallpike or supine roll test to confirm persistent BPPV
2. Perform additional repositioning maneuvers—success reaches 90–98% 4
3. Check for canal conversion (posterior → horizontal or vice versa; occurs in 6% of cases) 4, 3
4. Evaluate for multiple canal involvement or bilateral BPPV 4
5. Consider coexisting vestibular pathology if symptoms provoked by general head movements (not just positional) 4
6. Rule out CNS disorders if atypical features present 4

Treatment of Ménière's Disease

Diagnostic Criteria:

• ≥2 spontaneous vertigo episodes lasting 20 minutes to 12 hours 1
• Fluctuating low-to-mid-frequency sensorineural hearing loss documented on audiometry 1
• Fluctuating aural symptoms—tinnitus and fullness in affected ear 1

Key Distinguishing Feature from Vestibular Migraine:

Ménière's = fluctuating hearing loss that worsens over time; Vestibular migraine = stable or absent hearing loss 1, 2

Treatment Algorithm:

1. Dietary sodium restriction (<1500–2000 mg/day) 5
2. Diuretics (e.g., hydrochlorothiazide 25 mg + triamterene 37.5 mg daily) for persistent symptoms 1, 5
3. Oral corticosteroids for acute attacks 1
4. Intratympanic gentamicin for refractory vertigo unresponsive to medical therapy 1
5. Endolymphatic sac decompression surgery reserved for medical treatment failures 1

Common Pitfall:

35% of Ménière's patients also meet criteria for vestibular migraine—both conditions can coexist 1

Treatment of Vestibular Neuritis

Clinical Presentation:

• Single prolonged episode of severe rotational vertigo lasting 12–36 hours, followed by 4–5 days of decreasing disequilibrium 1
• Unidirectional horizontal nystagmus that persists without positional changes 1
• No hearing loss (distinguishes from labyrinthitis) 1, 6

Treatment Protocol:

1. Vestibular suppressants (meclizine 25 mg TID, dimenhydrinate 50 mg TID, or lorazepam 0.5 mg BID) for acute phase only (first 2–3 days)—prolonged use delays central compensation 5, 7
2. Antiemetics (prochlorperazine 10 mg IV or metoclopramide 10 mg IV) for severe nausea/vomiting 1
3. Early vestibular rehabilitation therapy (begin within 48–72 hours) to promote central compensation 4, 5
4. Corticosteroids (methylprednisolone 100 mg daily × 3 days, taper over 3 weeks) may improve vestibular function recovery 7

Vestibular Rehabilitation Components:

• Habituation exercises—repeated exposure to provocative movements 4
• Gaze stabilization exercises—VOR adaptation 4
• Balance retraining and fall prevention 4

VRT significantly improves gait stability compared to medication alone, particularly in elderly patients or those with heightened fall risk 4, 1

When NOT to Order Imaging or Testing

Do NOT obtain neuroimaging or vestibular testing for 1, 2:

• Typical BPPV with positive Dix-Hallpike test and no red-flag features
• Acute persistent vertigo with normal neurologic exam and peripheral-consistent HINTS (by trained examiner) in low vascular risk patients
• Nonspecific dizziness without vertigo, ataxia, or neurologic deficits

CT head has <1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts—if imaging is needed, obtain MRI with diffusion-weighted imaging 1

Special Populations

Elderly Patients:

• BPPV present in 9% of elderly patients referred for geriatric evaluation; 75% had fallen within prior 3 months 1
• Assess for impaired mobility, CNS disorders, lack of home support, and polypharmacy before treatment 4, 3
• Medication review essential—antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic dizziness 1

Recurrence Counseling:

• BPPV recurrence rates: 10–18% at 1 year, 30–50% at 5 years 3
• Each recurrence treated with repeat CRP maintains 90–98% success rate 3
• Vestibular rehabilitation after successful repositioning reduces recurrence by approximately 50% 3