From the Guidelines
For persistent vertigo not improving with the Dix-Hallpike maneuver, a comprehensive medical workup is essential to rule out underlying serious conditions, and this should include neuroimaging, vestibular function testing, and laboratory studies. The Dix-Hallpike maneuver, as discussed by Bhattacharyya et al 1, is the gold standard for diagnosing posterior canal BPPV, but its accuracy may vary, and a negative result does not necessarily rule out the condition. Therefore, if vertigo persists, it is crucial to proceed with a thorough evaluation.
Recommended Workup
- Neuroimaging: Brain MRI with contrast is recommended to rule out central nervous system pathologies like stroke, multiple sclerosis, or vestibular schwannoma.
- Vestibular Function Testing: This should include videonystagmography (VNG), rotational chair testing, vestibular evoked myogenic potentials (VEMPs), and video head impulse test (vHIT) to assess vestibular function comprehensively.
- Laboratory Studies: Complete blood count, metabolic panel, thyroid function tests, vitamin B12 levels, and inflammatory markers should be included.
- Audiometry: Important to evaluate for hearing loss that may accompany certain vestibular disorders.
Management and Referral
Consider referral to specialists including neurology, otolaryngology, or a dedicated vestibular specialist. While awaiting diagnosis, symptomatic treatment may include vestibular suppressants like meclizine 12.5-25mg every 4-6 hours as needed, or benzodiazepines like diazepam 2-5mg every 8 hours for severe symptoms, though these should be used short-term 1. Vestibular rehabilitation therapy should be initiated early as it improves outcomes regardless of the underlying cause by promoting central compensation. This comprehensive approach is necessary because persistent vertigo may indicate more serious conditions when not responding to positioning maneuvers, which typically resolve benign paroxysmal positional vertigo.
From the Research
Diagnostic Approach for Persistent Vertigo
The diagnostic approach for persistent vertigo that is not improving with the Dix-Hallpike maneuver involves a combination of clinical evaluation and additional tests.
- A detailed history and physical examination, including orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the HINTS (head-impulse, nystagmus, test of skew) examination, can help identify the underlying cause of vertigo 2.
- The Dix-Hallpike maneuver is a useful test for diagnosing benign paroxysmal positional vertigo (BPPV), but it may not always be effective in identifying other vestibular causes of vertigo 3.
- Electronystagmography (ENG) can be used to diagnose secondary BPPV and other vestibular disorders, such as unilateral or bilateral canal paresis and Meniere's disease 4.
- Vestibular rehabilitation is a helpful treatment for many peripheral and central etiologies of vertigo, including BPPV 2.
Additional Tests and Considerations
Additional tests, such as electrocochleography and imaging studies (e.g., CT or MRI scans), may be necessary to rule out central causes of vertigo or to further evaluate vestibular function 4, 2.
- The presence of reverse nystagmus during the Dix-Hallpike maneuver may be associated with a better prognosis for treatment with canalith repositioning procedures (e.g., Epley maneuver) 5.
- The absence of reverse nystagmus may predict poor success for the Epley maneuver, and repetitive repositioning maneuvers may be required to achieve successful treatment 5.