How should I evaluate and manage a patient presenting with positional dizziness (positional vertigo)?

Evaluation and Management of Positional Dizziness

Perform the Dix-Hallpike maneuver bilaterally at the bedside to diagnose posterior canal BPPV, and if positive, immediately treat with the Epley canalith repositioning procedure—this approach achieves 80% resolution after 1-3 treatments and avoids unnecessary imaging, medications, and specialist referrals. 1

Initial Diagnostic Approach

History Taking: Focus on Timing and Triggers

• Ask specifically about episode duration and triggers rather than accepting vague descriptions like "dizzy" or "spinning," as patient terminology is unreliable for diagnosis 2, 3
• Episodes lasting <1 minute triggered by head position changes (rolling in bed, looking up, bending forward) strongly suggest BPPV, which accounts for 42% of all vertigo presentations 1, 2
• Document the latency period: typical BPPV shows 5-20 seconds between position change and symptom onset 1
• Note fatigability: symptoms that decrease with repeated movements support BPPV 1

Red Flags Requiring Immediate MRI (Without Contrast)

Stop and order urgent neuroimaging if any of the following are present:

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke)—even with normal neurologic exam, 11-25% harbor posterior-circulation stroke 2
• New severe headache accompanying vertigo 2
• Focal neurologic deficits: dysarthria, limb weakness, sensory loss, diplopia, dysphagia, Horner's syndrome 2, 4
• Inability to stand or walk independently (severe postural instability with falling) 2, 4
• Sudden unilateral hearing loss 2
• Down-beating or pure vertical nystagmus without torsional component 2, 4
• Direction-changing nystagmus without head-position change 2, 4
• Baseline nystagmus present without provocative maneuvers 2, 4
• Failure to improve after appropriate canalith repositioning treatment 2, 4

Physical Examination Protocol

Step 1: Perform Dix-Hallpike Maneuver (Bilateral)

Technique 1:

1. Position patient seated on examination table so head can extend 20° beyond the edge when supine
2. Turn patient's head 45° to the right
3. Rapidly move patient from sitting to supine with head extended 20° backward
4. Observe for 60 seconds
5. Return to sitting and repeat on opposite side

Positive Test Findings (confirms posterior canal BPPV) 1, 2:

• Latency: 5-20 seconds (may extend to 60 seconds in rare cases) before nystagmus onset
• Nystagmus pattern: torsional and upbeating toward the affected (dependent) ear
• Duration: symptoms and nystagmus resolve within 60 seconds
• Fatigability: intensity decreases with repeated testing
• Subjective vertigo accompanies the nystagmus

Central Pathology Findings (mandate immediate MRI) 2, 4:

• Immediate onset without latency
• Pure vertical nystagmus without torsional component
• Persistent nystagmus that does not resolve within 60 seconds
• No fatigability with repeated testing
• Nystagmus not suppressed by visual fixation

Step 2: If Dix-Hallpike Negative, Perform Supine Roll Test

This evaluates horizontal canal BPPV, which accounts for 10-15% of BPPV cases 1:

1. Position patient supine with head flat
2. Rapidly turn head 90° to one side
3. Observe for horizontal nystagmus and vertigo
4. Return to center and repeat to opposite side

Treatment Algorithm

For Positive Dix-Hallpike (Posterior Canal BPPV)

Immediately perform the Epley canalith repositioning maneuver 1, 3:

• Success rate: 80% after 1-3 treatments; 90-98% with additional maneuvers if initial treatment fails 1, 2
• Repeat the maneuver 2-3 times in the same session—this is safe and increases immediate success 5
• Do NOT prescribe postural restrictions after the procedure (strong recommendation against) 1

Medications: What NOT to Do

Do NOT routinely prescribe vestibular suppressants (meclizine, antihistamines, benzodiazepines) for BPPV 1, 3:

• These medications delay central compensation and have no therapeutic benefit for BPPV 1, 6
• Consider only for severe nausea/vomiting during the maneuver itself 3

For Horizontal Canal BPPV

Use Gufoni or Lempert roll (barbecue) maneuvers 7, 8:

• 88% of horizontal canal BPPV resolves with ≤2 treatments 5

Imaging Decisions

Do NOT Order Imaging When:

• Dix-Hallpike is positive with typical nystagmus pattern 1, 2
• No red-flag features are present 1
• Neurologic examination is normal 2
• Diagnostic yield of CT in isolated dizziness is <1% 2, 3

Order MRI Brain (Without Contrast) When:

• Any red-flag feature listed above is present 2, 3
• Atypical nystagmus pattern on Dix-Hallpike 1
• BPPV treatment fails after appropriate repositioning maneuvers 2, 4
• Note: CT head misses most posterior-circulation strokes (sensitivity 10-40%); MRI is mandatory when stroke is suspected 2, 3

Follow-Up and Reassessment

• Re-evaluate within 1 month to confirm symptom resolution 1, 3
• If symptoms persist, repeat Dix-Hallpike to confirm ongoing BPPV versus alternative diagnosis 3, 5
• Consider vestibular rehabilitation for persistent imbalance between episodes (reported in ~50% of BPPV patients) 1, 3

Common Clinical Pitfalls

Pitfall 1: Assuming Normal Exam Excludes Stroke

75-80% of posterior-circulation strokes present without focal neurologic deficits 2, 4—always consider vascular risk factors and age >50 years as independent indications for imaging.

Pitfall 2: Relying on Patient's Description of "Spinning"

True rotational vertigo is not always reported in BPPV; patients may describe lightheadedness, nausea, or feeling "off balance" 1—focus on timing (seconds) and triggers (position change) instead 2, 3.

Pitfall 3: Ordering CT Instead of MRI

CT has <1% diagnostic yield for isolated dizziness and misses most posterior-circulation infarcts 2, 3—if stroke is suspected, MRI with diffusion-weighted imaging is required.

Pitfall 4: Prescribing Meclizine for BPPV

Vestibular suppressants have no therapeutic effect on BPPV and delay recovery 1, 6—the only effective treatment is canalith repositioning.

Pitfall 5: Missing Multiple Canal Involvement

Bilateral BPPV or multiple canal involvement requires more treatments 5—always test both sides and be prepared to repeat maneuvers.

Pitfall 6: Overlooking Post-Treatment Otolithic Crisis

19% of patients experience down-beating nystagmus and vertigo after the first or second Epley maneuver 5—warn patients about fall risk immediately post-treatment and ensure safe ambulation before discharge.

Pitfall 7: Assuming Nystagmus During Epley Predicts Success

Presence or absence of nystagmus and symptoms during the Epley maneuver does NOT correlate with treatment success 5—complete the maneuver regardless and reassess with repeat Dix-Hallpike.