What is the diagnosis and first‑line treatment for an adult who has brief episodes of vertigo lasting seconds to minutes triggered by changes in head position with characteristic nystagmus?

Benign Paroxysmal Positional Vertigo (BPPV): Diagnosis and Treatment

The diagnosis is posterior canal BPPV, confirmed by performing the Dix-Hallpike maneuver bilaterally, and the first-line treatment is immediate canalith repositioning with the Epley maneuver performed at the bedside. 1

Diagnostic Criteria

History:

• Episodes of vertigo lasting 10-60 seconds (not minutes), triggered specifically by head position changes relative to gravity 2
• Common triggers include rolling over in bed, looking upward, or bending forward 1
• Patients describe a rotational or spinning sensation, not simple lightheadedness 2
• Approximately 50% report subjective imbalance between episodes, but this does not produce sustained ataxia 1

Physical Examination - The Dix-Hallpike Maneuver:

The Dix-Hallpike maneuver is the gold standard diagnostic test and must be performed bilaterally 1:

• Rotate the patient's head 45° to one side while seated, then rapidly move them to supine position with head extended 20° backward 1

• Positive test criteria (all must be present): 1

  • Latency period of 5-20 seconds (rarely up to 1 minute) between positioning and symptom onset
  • Torsional (rotatory) upbeating nystagmus toward the affected ear
  • Vertigo and nystagmus that crescendo then resolve within 60 seconds from nystagmus onset
  • Subjective vertigo accompanies the nystagmus

• If the first side is negative, immediately test the opposite side before concluding the maneuver is negative 1

• Sensitivity is approximately 82%, specificity 71%; a negative result does not exclude BPPV and may require repeat testing at a later visit 3

If Dix-Hallpike is negative but suspicion remains:

• Perform the supine roll test to evaluate for lateral canal BPPV, which accounts for 10-15% of cases 3, 2

First-Line Treatment

Perform the Epley canalith repositioning maneuver immediately after confirming the diagnosis 2:

• Success rate is approximately 80% after 1-3 treatments, rising to 90-98% with additional maneuvers if needed 2
• Some patients experience immediate resolution; others have transient motion-sickness-type symptoms and mild instability lasting hours to days 2

Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) as they do not address the mechanical etiology and may delay central compensation 2

Imaging and Laboratory Testing

No routine imaging or laboratory testing is indicated for patients meeting typical BPPV criteria with characteristic nystagmus on Dix-Hallpike and no red-flag features 3, 2:

• CT head has diagnostic yield <1% for isolated positional dizziness 3, 2
• MRI yields only 4% in isolated dizziness without neurologic findings 3, 2
• Routine audiometry is not recommended for confirmed BPPV 3

Order urgent MRI brain with diffusion-weighted imaging if any red flags present: 3, 2

• Sudden unilateral hearing loss
• Inability to stand or walk (severe postural instability)
• New severe headache
• Down-beating or direction-changing nystagmus
• Normal head-impulse test (suggests central cause)
• Focal neurologic deficits

Follow-Up and Recurrence Management

• Reassess within 1 month after initial treatment to confirm resolution or identify persistent BPPV 3, 2
• Counsel patients that BPPV may recur; they should return promptly for repeat repositioning 2
• Refer for vestibular rehabilitation therapy if vertigo persists after 2-3 repositioning attempts 2
• Advise fall-prevention strategies, as dizziness increases fall risk approximately 12-fold in older adults 2

Critical Diagnostic Pitfalls to Avoid

• Do not rely solely on patient descriptors of "spinning" versus "lightheadedness"; prioritize episode timing (<60 seconds), positional triggers, and nystagmus characteristics 3, 2
• Even with atypical histories, up to one-third of patients still demonstrate positional nystagmus on Dix-Hallpike testing 1
• A positive Romberg test excludes isolated BPPV and indicates concurrent central vestibular disorder, peripheral neuropathy, or posterior-column dysfunction requiring further evaluation 4
• Do not order comprehensive vestibular testing for straightforward BPPV; it delays definitive treatment 2
• Posterior canal BPPV accounts for 85-95% of all BPPV cases, making it by far the most common presentation 2