What is the recommended management for a generally healthy adult presenting with brief episodes of positional vertigo triggered by changes in head position?

Management of Brief Positional Vertigo in Healthy Adults

The recommended first-line management is immediate canalith repositioning with the Epley maneuver after confirming the diagnosis with a bilateral Dix-Hallpike test—no imaging or medication is needed for typical presentations. 1

Diagnostic Confirmation

Perform the Dix-Hallpike maneuver bilaterally to confirm benign paroxysmal positional vertigo (BPPV), which accounts for 42% of all vertigo presentations and is the most common cause of brief positional vertigo. 1 The test involves moving the patient from seated to supine with the head turned 45° to one side and extended 20° backward. 1

Positive Test Findings (Peripheral BPPV)

• Latency period of 5–20 seconds before symptoms begin 1
• Torsional, upbeating nystagmus beating toward the affected ear 1
• Crescendo-decrescendo pattern with vertigo and nystagmus that increase then resolve within 60 seconds 1
• Fatigability with repeated testing 1

Red-Flag Findings (Central Pathology)

• Immediate onset without latency 1
• Pure vertical nystagmus (up-beating or down-beating) without torsional component 1, 2
• Persistent nystagmus that does not resolve within 60 seconds 1
• Direction-changing nystagmus without head position changes 2
• Nystagmus not suppressed by visual fixation 2

If the Dix-Hallpike is negative, perform the supine roll test to evaluate for lateral-canal BPPV, which accounts for 10–15% of BPPV cases. 1

First-Line Treatment

Immediately perform the Epley canalith repositioning maneuver upon confirming BPPV with a positive Dix-Hallpike test. 1 This achieves:

• 80% success rate after 1–3 treatments 1
• 90–98% success rate with additional maneuvers if initial treatment fails 1

Do NOT prescribe vestibular suppressants (meclizine, dimenhydrinate, benzodiazepines) for BPPV, as they do not address the mechanical pathology and may delay central compensation. 1

When Imaging Is NOT Indicated

No neuroimaging is required when all of the following are present: 1

• Positive Dix-Hallpike test with typical peripheral nystagmus pattern
• Normal neurologic examination
• No red-flag features (see below)
• Age <50 years or absence of vascular risk factors

The diagnostic yield of CT is <1% and MRI is only 4% in isolated positional dizziness without red flags. 1, 3

Red Flags Requiring Urgent MRI Brain (Without Contrast)

Obtain immediate MRI with diffusion-weighted imaging if any of the following are present: 1

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)
• Severe postural instability with falling
• New severe headache accompanying vertigo
• Focal neurologic deficits (dysarthria, limb weakness, sensory loss, diplopia, Horner's syndrome)
• Down-beating or purely vertical nystagmus without torsional component
• Direction-changing nystagmus
• Baseline nystagmus present without provocative maneuvers
• Normal head-impulse test (suggests central cause)
• Skew deviation on alternate cover testing
• Sudden unilateral hearing loss
• Failure to respond to appropriate canalith repositioning therapy

Critical pitfall: 75–80% of patients with posterior circulation stroke presenting as acute vestibular syndrome have NO focal neurologic deficits on standard examination. 1, 3 Do not assume a normal neurologic exam excludes stroke in high-risk patients.

Follow-Up and Recurrence Management

Reassess within 1 month after initial treatment to document resolution or persistence of symptoms. 1 If symptoms persist:

• Repeat the Dix-Hallpike test to confirm ongoing BPPV 1
• Perform additional repositioning maneuvers (success rate 90–98% with repeat procedures) 1
• Consider vestibular rehabilitation therapy if vertigo persists after 2–3 repositioning attempts 1

Counsel patients about: 1

• Recurrence risk (BPPV commonly recurs)
• Fall risk (dizziness increases fall risk 12-fold in elderly patients) 1
• Home safety assessment
• Prompt return if symptoms recur for repeat repositioning

Common Diagnostic Pitfalls

• Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus instead on timing (seconds for BPPV) and triggers (head position changes). 1
• About 50% of BPPV patients describe symptoms as "lightheadedness" or "off-balance" rather than classic rotational vertigo. 1
• Do not order routine imaging for typical BPPV—the yield is <1% and most findings are incidental. 1
• Do not substitute CT for MRI when stroke is suspected—CT misses most posterior circulation infarcts (sensitivity only 10–20%). 1, 3