Nervous System & Special Senses

Vertigo: peripheral vs central and Dix-Hallpike

Clinical Overview and When to Suspect Vertigo

— Peripheral lesions: labyrinth or CN VIII (BPPV, vestibular neuritis, labyrinthitis, Ménière, perilymphatic fistula, acoustic neuroma)

— Central lesions: brainstem or cerebellum (posterior circulation stroke/TIA, MS plaque, vestibular migraine, cerebellar hemorrhage, tumor)

— Patient describes room spinning, environmental motion, or being pulled to one side

— Triggered or worsened by head position changes

— Associated nausea/vomiting, nystagmus, gait instability, hearing change, or aural fullness

— Triggered episodic (seconds, positional) → BPPV

— Spontaneous episodic (minutes–hours) → Ménière, vestibular migraine, TIA

— Acute continuous (days, with nystagmus) → vestibular neuritis vs posterior stroke ("AVS")

— Chronic → bilateral vestibulopathy, anxiety, cerebellar degeneration

Board pearl: Asking "What do you mean by dizzy?" is less reliable than asking about timing and triggers; patients reclassify their symptom on re-questioning, so anchor your workup on TiTrATE, not on the descriptor.

Vertigo = illusion of motion (spinning, tilting, rocking) caused by asymmetry in the vestibular system; distinct from presyncope, disequilibrium, or generalized lightheadedness

Epidemiology: lifetime prevalence ~20–30%; BPPV is the single most common cause in primary care, especially in adults >50 and post head-trauma patients

Anatomic framework — vestibular signal travels from semicircular canals/otoliths → CN VIII → vestibular nuclei (pons/medulla) → cerebellum, thalamus, cortex

When to suspect vertigo specifically (vs other dizziness):

Step 3 ambulatory framing — the family medicine task is to separate benign peripheral causes (treat in clinic) from central red flags (urgent imaging/admission); this hinges on bedside exam, not MRI for everyone

Timing/trigger heuristic (TiTrATE / ATTEST framework):

Presentation Patterns and Key History

— Timing: episodic vs continuous; duration of each episode

— Triggers: head position, standing, loud sounds (Tullio), Valsalva, stress, menstrual cycle

— Associated neuro symptoms: diplopia, dysarthria, dysphagia, dysmetria, weakness, numbness, ataxia ("5 D's + 3 N's")

— Auditory symptoms: unilateral hearing loss, tinnitus, aural fullness

— Vascular risk: age >60, HTN, DM, smoking, AFib, prior stroke, neck trauma/manipulation

— BPPV: <1 min spells triggered by rolling in bed, looking up ("top-shelf vertigo"), bending; no hearing loss

— Vestibular neuritis: days of continuous vertigo after viral URI; no hearing loss

— Labyrinthitis: same as neuritis plus hearing loss/tinnitus

— Ménière disease: episodic 20 min–24 hr vertigo + fluctuating low-frequency hearing loss + tinnitus + aural fullness

— Vestibular schwannoma: chronic imbalance + progressive unilateral sensorineural hearing loss

— Posterior circulation stroke/TIA: sudden, continuous, often with subtle brainstem signs; vertigo can be the sole symptom in AICA/PICA territory

— Vestibular migraine: recurrent vertigo + migraine features (photophobia, headache, aura); often history of motion sickness

— Cerebellar hemorrhage: severe occipital headache, vomiting, truncal ataxia — neurosurgical emergency

— Aminoglycosides (gentamicin) → bilateral vestibulotoxicity

— Loop diuretics, cisplatin, salicylates → ototoxicity

— Antihypertensives, benzodiazepines → presyncope or disequilibrium mimicking vertigo

Key distinction: Isolated vertigo lasting hours with normal exam in a vasculopath is a stroke until proven otherwise — vestibular migraine is a diagnosis of exclusion in patients >60 with vascular risk factors; do not anchor on migraine history.

Five history questions that drive 90% of the diagnosis:

Classic peripheral patterns:

Classic central patterns:

Medication history is high-yield:

Physical Exam Findings and Bedside Vestibular Testing

— Peripheral: unidirectional, horizontal-torsional, suppresses with visual fixation, fatigable, latency present

— Central: vertical (especially down-beating), pure torsional, direction-changing, does NOT suppress with fixation, no latency, no fatigue

— Head Impulse: abnormal (corrective saccade) = peripheral; normal = central (counterintuitive!)

— Nystagmus: direction-changing on gaze = central

— Test of Skew: vertical ocular misalignment on cover-uncover = central

— Any "central" finding → HINTS more sensitive than early MRI for posterior stroke (96–100% vs ~80%)

— Peripheral: can usually walk with mild veering toward affected side

— Central: cannot stand or walk without falling (truncal ataxia) — strong red flag

Step 3 management: In a clinic patient with continuous vertigo, normal head impulse, direction-changing nystagmus, or inability to stand → do not prescribe meclizine and send home; arrange urgent ED transfer for MRI with DWI (CT misses ~80% of posterior fossa strokes in first 24 hr).

General exam: orthostatic vitals (rule out presyncope), cardiac auscultation (AFib, AS), carotid/vertebral bruits, otoscopy (vesicles of Ramsay Hunt, cholesteatoma, effusion)

Cranial nerve exam: full CN II–XII; any deficit beyond vestibular = central until proven otherwise

Nystagmus characterization — single most discriminating finding:

HINTS exam (for acute vestibular syndrome — continuous vertigo >24 hr with nystagmus; NOT for episodic/positional vertigo):

Gait and truncal stability:

Cerebellar testing: finger-to-nose, heel-to-shin, rapid alternating movements, Romberg

Hearing: Weber/Rinne; unilateral SNHL with vertigo suggests labyrinthitis, Ménière, or AICA stroke (labyrinthine artery)

Diagnostic Workup — Dix-Hallpike and Initial Bedside Studies

— Patient seated, head turned 45° toward tested ear

— Rapidly lower to supine with head extended 20° below horizontal (hang head off table edge)

— Observe eyes ~30 seconds; repeat for opposite side

— Positive test: upbeating, torsional nystagmus toward the dependent ear, with latency 5–20 sec, duration <60 sec, fatigability on repeat

— Classic positive → diagnostic of ipsilateral posterior canal BPPV → proceed directly to Epley maneuver

— Negative Dix-Hallpike + positional symptoms → perform supine roll test for horizontal (lateral) canal BPPV (≈10–15%)

— Persistent, non-fatiguing, or vertical down-beating nystagmus on Dix-Hallpike → central positional vertigo → image the posterior fossa

— ECG if presyncope or palpitations (AFib, long QT, AV block)

— Orthostatic vitals in elderly/diabetic

— CBC, glucose, TSH, electrolytes only if systemic features

— Audiometry for any unilateral hearing complaint (Ménière, schwannoma)

— MRI brain with DWI + MRA posterior circulation — indicated for any central feature, HINTS-central, isolated AVS in vasculopath, new headache, or failure to improve in 48–72 hr

— CT head has poor sensitivity for posterior fossa stroke but is appropriate to rule out hemorrhage if available faster

CCS pearl: On CCS, ordering "Dix-Hallpike maneuver" in a patient with brief positional vertigo earns credit and unlocks the canalith repositioning (Epley) maneuver as the next correct order — skipping the maneuver to order MRI is a deduction.

Dix-Hallpike maneuver — gold standard for posterior canal BPPV (≈85–90% of BPPV cases):

Interpretation:

Contraindications/cautions: severe cervical stenosis, recent neck surgery, unstable carotid disease, severe kyphosis — modify with side-lying test

Initial labs/studies — most patients need no labs; targeted testing:

Imaging in primary care:

Diagnostic Workup — Advanced and Confirmatory Studies

— Low-frequency SNHL, fluctuating → Ménière disease (clinical criteria: ≥2 spontaneous vertigo episodes ≥20 min, audiometrically documented hearing loss, tinnitus/fullness)

— High-frequency SNHL with poor word recognition out of proportion to PTA → retrocochlear lesion → MRI IAC

— Videonystagmography (VNG) — quantifies nystagmus, caloric response; identifies unilateral vestibular hypofunction

— Video head impulse test (vHIT) — quantifies vestibulo-ocular reflex per canal

— Vestibular evoked myogenic potentials (VEMPs) — saccule (cervical VEMP) and utricle (ocular VEMP) function; abnormal in superior canal dehiscence, Ménière

— Rotary chair testing — bilateral vestibulopathy (e.g., gentamicin)

Board pearl: Unilateral progressive sensorineural hearing loss with disequilibrium = MRI IAC with gadolinium, not audiometry alone — vestibular schwannomas are missed when clinicians stop at "presbycusis." NF2 if bilateral schwannomas.

Audiometry (pure-tone + speech discrimination):

MRI internal auditory canal (IAC) with gadolinium — confirms vestibular schwannoma (CN VIII, often at cerebellopontine angle); also detects MS plaques, cerebellar lesions

MRI brain with DWI — gold standard for posterior circulation stroke; may be falsely negative in first 24–48 hr for small brainstem infarcts → repeat in 3–7 days if clinical suspicion remains

Vestibular function testing (refer to otology/audiology):

Posturography — quantifies postural control; used for rehab planning, not diagnosis

CT temporal bone — superior canal dehiscence syndrome (vertigo with loud sounds/Valsalva, Tullio phenomenon), cholesteatoma, otosclerosis

Carotid/vertebral imaging — CTA or MRA when posterior circulation stroke suspected; consider vertebral artery dissection in young patients after neck trauma/chiropractic manipulation

Echocardiogram + Holter — when embolic posterior stroke confirmed

Risk Stratification and First-Line Management Logic

— Step 1: Is this truly vertigo (illusion of motion)? If presyncope/disequilibrium, pivot workup

— Step 2: Apply TiTrATE — categorize by timing/triggers

— Step 3: Search for central red flags ("5 D's + 3 N's": dizziness, diplopia, dysarthria, dysphagia, dysmetria + nystagmus (vertical/direction-changing), numbness, nausea out of proportion)

— Step 4: Perform Dix-Hallpike if triggered/episodic; HINTS if acute continuous

— Step 5: Treat at bedside (Epley) or escalate (ED/MRI)

— Any HINTS-central finding

— Inability to stand/walk

— New neurologic deficit

— Sudden severe headache with vomiting

— Vasculopath >60 with acute spontaneous vertigo and any concerning feature

— Suspected vertebral artery dissection (neck pain + Horner + vertigo)

— Classic BPPV with positive Dix-Hallpike → in-office Epley

— Vestibular neuritis stabilized, ambulatory, normal HINTS → short steroid course + vestibular rehab

— Known Ménière disease with typical episode → counseling, salt/caffeine reduction, diuretic

— Vestibular migraine → migraine prophylaxis + trigger avoidance

Step 3 management: Document a clear follow-up plan in 48–72 hours for any patient sent home with "peripheral vertigo" — failure to reassess is a common malpractice pitfall when an evolving stroke is mislabeled as vestibular neuritis.

Triage decision tree for the family medicine clinic:

Disposition criteria for ED transfer:

Outpatient management appropriate for:

Vascular risk stratification in spontaneous AVS: ABCD² score has limited utility; use HINTS + age + risk factors instead — a patient with HTN/DM/AFib and isolated vertigo lasting hours has stroke risk approaching that of classic stroke presentation

Fall risk assessment — every elderly vertigo patient gets a Timed Up and Go and home safety review before discharge

Pharmacotherapy — Symptomatic and Disease-Specific

— Meclizine 25 mg PO q6–8h PRN — H1 antihistamine, first-line outpatient; sedating, anticholinergic (caution elderly — Beers criteria)

— Dimenhydrinate 50 mg PO q4–6h — similar profile

— Promethazine 25 mg PO/IM/PR — for vomiting; extrapyramidal risk, black box for IV (tissue necrosis)

— Ondansetron 4–8 mg ODT — antiemetic of choice; monitor QT

— Diazepam/lorazepam — reserve for severe refractory cases, short course

— Methylprednisolone taper (e.g., 100 mg → taper over 3 weeks) within 3 days of onset — improves vestibular recovery on caloric testing

— Antivirals not routinely recommended (no clear benefit unless HSV/VZV suspected — Ramsay Hunt gets valacyclovir + steroids)

— Early vestibular rehabilitation > prolonged suppressants

— Lifestyle: low-sodium diet (<1.5–2 g/d), caffeine/alcohol/nicotine reduction

— Hydrochlorothiazide 25 mg ± triamterene daily — first-line

— Betahistine — used in Europe, limited US availability

— Refractory: intratympanic gentamicin (chemical ablation) or dexamethasone

— Acute: triptans, NSAIDs, antiemetics

— Prophylaxis: propranolol, topiramate, amitriptyline, venlafaxine, flunarizine; CGRP antagonists emerging

— Avoid chronic meclizine

Board pearl: Chronic daily meclizine in elderly vertigo patients is a high-yield wrong answer — it causes falls, urinary retention, delirium, and prolongs recovery; the right answer is usually vestibular rehab + Epley if BPPV.

Vestibular suppressants — for acute, severe symptoms only, ≤48–72 hours; longer use delays central compensation and prolongs recovery

Vestibular neuritis specific:

Ménière disease:

Vestibular migraine:

BPPV: no pharmacotherapy is curative — Epley/Semont maneuvers are the treatment; meclizine only blunts symptoms during repositioning

Procedural Management — Canalith Repositioning Maneuvers

— Start in Dix-Hallpike position with affected ear down; hold 30–60 sec or until nystagmus stops

— Rotate head 90° to opposite side; hold 30–60 sec

— Roll body onto that shoulder, head turned further 90° (nose toward floor); hold 30–60 sec

— Sit up slowly with head tilted forward 20°

— Post-procedure: counsel that post-Epley activity restrictions (upright sleeping, soft collar) do not improve outcomes per current AAO-HNS guideline — no longer required

— Ménière: intratympanic gentamicin, endolymphatic sac decompression, labyrinthectomy (deafening), vestibular nerve section

— Vestibular schwannoma: observation with serial MRI (small, elderly), stereotactic radiosurgery (Gamma Knife), or microsurgical resection

— Superior canal dehiscence: middle fossa or transmastoid plugging/resurfacing

CCS pearl: After positive Dix-Hallpike, the next CCS order is "canalith repositioning procedure (Epley)"; follow with "counsel patient" and "schedule follow-up in 1–2 weeks" — this triad maximizes the management score.

Epley maneuver (posterior canal BPPV) — definitive treatment, 80–90% success rate in 1–2 sessions:

Semont (liberatory) maneuver — alternative for posterior canal BPPV, useful with neck mobility limitations

Lempert (BBQ roll) maneuver — for horizontal canal BPPV confirmed by supine roll test; 270–360° roll away from affected ear in 90° increments

Gufoni maneuver — alternative for horizontal canal BPPV, useful when patient cannot tolerate full BBQ roll

Brandt-Daroff exercises — home self-treatment; less effective than Epley but useful for recurrent BPPV or maintenance

Reassess in clinic at 1–2 weeks; repeat Dix-Hallpike — if still positive, repeat Epley; if persistently positive despite 2–3 sessions, refer to vestibular specialist and reconsider central positional vertigo

Procedural escalation for refractory disease:

Vestibular rehabilitation therapy (VRT) — structured gaze stabilization, habituation, and balance exercises; first-line for unilateral vestibular hypofunction (post-neuritis) and bilateral vestibulopathy

Special Populations — Elderly and Renal/Hepatic Impairment

— Sensory: vestibular hypofunction + visual impairment (cataracts) + proprioceptive loss (diabetic neuropathy) = "multisensory disequilibrium"

— Polypharmacy: review for ototoxic drugs, sedatives, antihypertensives, alpha-blockers (orthostasis)

— Beers Criteria: avoid meclizine, diphenhydramine, scopolamine, benzodiazepines chronically — anticholinergic burden, falls, delirium

— Preferred: vestibular rehab, Epley for BPPV, ondansetron for short-term nausea

— Vitamin D supplementation if deficient

— Home safety (grab bars, lighting, remove rugs)

— Physical therapy with balance training

— Vision and hearing optimization

— Footwear assessment

— Meclizine: no formal dose adjustment, but use lowest effective dose

— Aminoglycoside avoidance — eGFR <60 dramatically increases vestibulotoxicity risk; monitor trough levels and check baseline + serial audiometry/balance if unavoidable

— HCTZ for Ménière: limited efficacy at eGFR <30; consider alternatives

— Acetazolamide (used in some episodic ataxias) requires renal dosing

— Promethazine, prochlorperazine: hepatic metabolism, increased sedation risk

— Topiramate (vestibular migraine prophylaxis): generally safe but monitor for metabolic acidosis

— Diazepam: prolonged half-life — prefer lorazepam (glucuronidation, hepatic-sparing)

Step 3 management: In an 80-year-old with recurrent falls and positional vertigo, the highest-yield outpatient interventions are Epley maneuver, deprescribing anticholinergics, and referral to vestibular PT — not adding meclizine.

Elderly (>65) — vertigo is multifactorial; address all contributors:

BPPV in elderly is highly prevalent (often missed as "just old age dizziness"); always Dix-Hallpike before labeling as nonspecific

Fall prevention bundle at every visit:

Renal impairment:

Hepatic impairment:

Cognitive impairment: vestibular suppressants may unmask or worsen dementia symptoms; favor non-pharmacologic treatment whenever possible

Special Populations — Pregnancy, Pediatrics, and Other Subgroups

— Increased incidence of BPPV (calcium metabolism shifts) and vestibular migraine (hormonal)

— Epley maneuver is safe in all trimesters — first-line

— Avoid: high-dose meclizine in late pregnancy if possible (category B but limited data); benzodiazepines (cleft palate risk first trimester, neonatal withdrawal); ondansetron — controversial first trimester but generally used

— Preferred symptomatic: vitamin B6 + doxylamine, promethazine (cat C, short term), positional measures

— Ménière flares often improve in pregnancy; salt restriction continues

— Vertigo is uncommon and warrants thorough workup

— Benign paroxysmal vertigo of childhood — brief episodes in toddlers; migraine precursor (50% develop migraine later); reassurance, no treatment

— Vestibular migraine — most common cause of episodic vertigo in children/adolescents

— Otitis media with effusion — disequilibrium, not true vertigo; treat underlying ear disease

— Posterior fossa tumors (medulloblastoma, ependymoma) — morning headache, vomiting, ataxia → MRI is mandatory for any pediatric ataxia/persistent vertigo

— Vestibular schwannoma in a child = NF2 until proven otherwise — screen for café-au-lait, family history

— Post-traumatic BPPV common after head impact — Dix-Hallpike before clearing return to play

— Persistent post-concussive vertigo benefits from early vestibular rehabilitation

— DOT/FAA regulations: any vertigo episode generally disqualifies until resolved and cleared by specialist; document return-to-duty clearance carefully

— Divers: history of vertigo → ENT clearance to rule out Eustachian dysfunction, perilymph fistula

Board pearl: Benign paroxysmal vertigo of childhood is a migraine variant, not BPPV — no Dix-Hallpike positivity, no repositioning maneuver needed; the family history of migraine seals the diagnosis.

Pregnancy:

Postpartum — BPPV common; screen with Dix-Hallpike in any new mother with positional dizziness

Pediatrics:

Athletes / post-concussion:

Pilots, divers, commercial drivers:

Complications and Adverse Outcomes

— Hip fractures, subdural hematomas, wrist fractures — leading cause of vertigo-related morbidity in elderly

— Each fall increases fear-avoidance, leading to deconditioning and further falls (downward spiral)

— Mortality after hip fracture in elderly: ~20–30% at 1 year

— Most feared and most litigated complication in primary care/ED vertigo evaluation

— Mislabeling as "vestibular neuritis" delays tPA window (4.5 hr) and thrombectomy (up to 24 hr for select posterior)

— Cerebellar infarct can develop malignant edema 24–72 hr later → obstructive hydrocephalus and herniation → suboccipital decompression emergency

— Progressive hearing loss, brainstem compression, hydrocephalus, facial nerve compromise

— Permanent low- then high-frequency hearing loss

— Tumarkin's otolithic crisis (drop attacks) — sudden falls without LOC; major injury risk

— Bilateral involvement in 25–45% over decades

— Delayed central compensation → persistent disequilibrium

— Anticholinergic toxicity in elderly (delirium, urinary retention, constipation, glaucoma exacerbation)

— Dependence on benzodiazepines

— Chronic (>3 months) non-vertiginous dizziness following an acute vestibular event; worsened by upright posture, motion, visual stimuli

— Treatment: SSRI/SNRI + vestibular rehab + CBT, NOT vestibular suppressants

Key distinction: Drop attacks without LOC in a patient with known Ménière = Tumarkin crisis, not seizure or cardiac syncope — high injury risk warrants escalation to intratympanic gentamicin or surgical referral.

Falls and fall-related injury:

Missed posterior circulation stroke:

Vestibular schwannoma untreated:

Ménière disease progression:

Chronic vestibular suppressant use complications:

Persistent Postural-Perceptual Dizziness (PPPD):

Iatrogenic complications of Epley: rare neck injury, conversion to horizontal canal BPPV (10%), vomiting during maneuver

When to Escalate Care — ED, Consult, and Inpatient Triage

— Any HINTS-central finding (normal head impulse, direction-changing nystagmus, skew deviation)

— Vertigo + any focal neuro deficit (5 D's + 3 N's)

— Inability to stand or walk unaided

— Sudden severe headache, especially occipital, with vomiting → cerebellar hemorrhage

— Neck pain or trauma preceding vertigo → vertebral artery dissection

— New unilateral deafness with vertigo → AICA stroke vs labyrinthitis (cannot distinguish clinically — image)

— Vasculopath >60 with acute spontaneous AVS

— Confirmed posterior circulation stroke/TIA → stroke unit, dual antiplatelet if appropriate, statin, secondary prevention

— Cerebellar infarct with edema risk → neurosurgery consult, ICU monitoring for first 72 hr (peak edema window)

— Intractable vomiting with dehydration/electrolyte derangement → IV fluids, antiemetics

— Suspected meningitis/encephalitis with vertigo → LP, empiric antibiotics

— Neurology: any central feature, vestibular migraine refractory to first-line prophylaxis, suspected MS

— Otolaryngology/Neurotology: refractory BPPV (>2 failed Epleys), Ménière, suspected schwannoma, superior canal dehiscence

— Audiology: any unilateral hearing complaint

— Vestibular PT: post-neuritis, chronic vestibulopathy, PPPD, post-concussion

— Cardiology: when vertigo is actually presyncope (AFib, AS, long QT)

— Suspected schwannoma awaiting MRI

— Ménière for audiometry and treatment plan

— Recurrent BPPV (>3 episodes/year) for further evaluation

CCS pearl: When CCS gives you a 68-year-old vasculopath with continuous vertigo and direction-changing nystagmus, the correct sequence is: NPO → IV access → STAT MRI brain with DWI/MRA → neurology consult → admit to stroke unit — not "meclizine PO and discharge."

Send to ED immediately:

Inpatient admission criteria:

Specialty consultation:

Urgent outpatient referral (within 1–2 weeks):

Transfer of care considerations: send Dix-Hallpike findings, HINTS results, imaging, and treatment attempted in the referral note — incomplete handoffs delay diagnosis

Key Differentials — Same-Category (Vestibular) Causes

Board pearl: "Vertigo + hearing loss" narrows to four: labyrinthitis, Ménière, vestibular schwannoma, or AICA stroke — the first three are episodic/chronic; acute sudden onset with vascular risk = AICA stroke, image immediately.

BPPV — seconds, positional, fatigable, upbeating torsional on Dix-Hallpike; no hearing loss; Epley curative

Vestibular neuritis — days of continuous spontaneous vertigo, unidirectional horizontal nystagmus suppressed by fixation, abnormal head impulse, no hearing loss, post-viral; steroids within 72 hr

Labyrinthitis — neuritis + acute SNHL/tinnitus; same management plus audiometry; must distinguish from AICA stroke (image if any central sign)

Ménière disease — episodic 20 min–24 hr vertigo + fluctuating low-frequency SNHL + tinnitus + aural fullness; tetrad classic; treat with sodium restriction + HCTZ

Vestibular migraine — recurrent vertigo 5 min–72 hr with migraine features; no persistent hearing loss; ICHD-3 criteria; treat with migraine prophylaxis

Vestibular schwannoma (acoustic neuroma) — chronic imbalance, progressive unilateral SNHL with poor word recognition, tinnitus; MRI IAC with gad; observation, radiosurgery, or microsurgery

Superior canal dehiscence — vertigo with loud sounds (Tullio), Valsalva, autophony, pulsatile tinnitus; CT temporal bone shows dehiscence; surgical plugging if disabling

Perilymphatic fistula — vertigo + hearing loss after barotrauma, head trauma, straining; bed rest, surgical repair if persistent

Bilateral vestibulopathy — chronic oscillopsia, gait instability worse in dark; often aminoglycoside-induced; rotary chair confirms; vestibular rehab mainstay

Cervicogenic dizziness — disequilibrium with neck pain/motion; diagnosis of exclusion; PT and pain management

Mal de débarquement — persistent rocking after sea/air travel; women >> men; vestibular rehab, SSRIs

Persistent Postural-Perceptual Dizziness (PPPD) — chronic dizziness >3 months post-vestibular event; SSRI + CBT + VRT

Key Differentials — Other-Category Causes

— Orthostatic hypotension — drop ≥20/10 within 3 min standing; review antihypertensives, alpha-blockers, diuretics, autonomic neuropathy

— Atrial fibrillation, AV block, sinus node dysfunction — palpitations, syncope; ECG, Holter, loop recorder

— Aortic stenosis — exertional presyncope, crescendo-decrescendo murmur; echo

— Long QT, Brugada — family history of sudden death; ECG

— Subclavian steal — vertigo with arm exercise + BP differential between arms

— Posterior circulation TIA/stroke — covered above

— Multiple sclerosis — vertigo + INO, optic neuritis, sensory level; MRI with periventricular plaques

— Cerebellar hemorrhage/tumor — headache, ataxia, vomiting; CT/MRI

— Chiari malformation — cough-induced vertigo, occipital headache; MRI shows tonsillar descent

— Episodic ataxias (EA1, EA2) — autosomal dominant, acetazolamide-responsive (EA2)

— Hypoglycemia — diaphoresis, tremor; fingerstick

— Hyper/hypothyroidism, anemia, dehydration

— Panic disorder, generalized anxiety — dizziness with hyperventilation, paresthesias, derealization; not true vertigo

— Somatic symptom disorder — chronic multifocal symptoms

— Aminoglycosides, cisplatin, loop diuretics, salicylates — ototoxic

— Alcohol, sedative-hypnotics — cerebellar depression

— Antihypertensives, alpha-blockers — orthostasis

— Phenytoin, carbamazepine — at toxic levels cause nystagmus, ataxia

— Ramsay Hunt (VZV) — vesicles in ear canal, facial palsy, vertigo, hearing loss; valacyclovir + prednisone

— Lyme disease — facial palsy + vertigo in endemic area

— Syphilis (otosyphilis) — chronic SNHL/vertigo; treponemal testing

— HIV — opportunistic CNS infection, antiretroviral ototoxicity

Key distinction: "Dizziness with palpitations triggered by standing" is cardiovascular presyncope, not vertigo — the workup pivots to ECG, orthostatics, and Holter, and Dix-Hallpike will be a wasted step.

Cardiovascular (presyncope masquerading as vertigo):

Neurologic (central):

Metabolic/endocrine:

Psychiatric:

Drug/toxin-induced:

Infectious:

Secondary Prevention, Discharge, and Long-Term Plan

— Teach Brandt-Daroff exercises for home self-treatment of mild recurrences

— Educate on triggers: rolling in bed, looking up, dental chair, hairdresser position

— Consider vitamin D supplementation if deficient — emerging evidence of reduced recurrence

— Treat underlying osteoporosis (also reduces recurrence rates)

— Vestibular rehabilitation 2–6 weeks

— Taper off vestibular suppressants by day 3–5

— Most recover fully within 6 weeks; persistent symptoms → evaluate for PPPD

— Low-sodium diet (<1.5–2 g/d), limit caffeine/alcohol/nicotine

— HCTZ daily; betahistine (if available)

— Stress management, sleep hygiene

— Step-up: intratympanic dexamethasone → intratympanic gentamicin → surgery

— Audiogram every 6–12 months

— Hearing aids when threshold criteria met; cochlear implant if severe bilateral SNHL

— Identify and avoid triggers (sleep deprivation, missed meals, MSG, aged cheese, red wine, stress)

— Daily prophylaxis if ≥4 episodes/month

— Headache diary

— Antiplatelet (aspirin or clopidogrel; DAPT 21–90 days if minor stroke/high-risk TIA per CHANCE/POINT)

— High-intensity statin (atorvastatin 80 mg or rosuvastatin 40 mg) — LDL goal <70 mg/dL

— BP control <130/80; A1c <7% in most diabetics

— Anticoagulation if AFib (DOAC preferred)

— Smoking cessation, Mediterranean diet, 150 min/week aerobic exercise

— Carotid/vertebral imaging if not already done

Step 3 management: Every Ménière patient leaves the visit with a written sodium-restriction handout, HCTZ prescription, and audiology referral — verbal counseling alone is insufficient and a common Step 3 wrong answer.

BPPV — recurrence prevention (~50% recur within 5 years):

Vestibular neuritis:

Ménière disease — long-term plan:

Vestibular migraine:

Posterior circulation stroke survivor (secondary prevention bundle):

Driving counseling: avoid driving during active vertigo; many states require physician reporting of unsafe drivers — know your state law

Follow-Up, Monitoring, and Rehabilitation

— BPPV post-Epley: 1–2 weeks; repeat Dix-Hallpike; if positive, repeat Epley; if negative, discharge with Brandt-Daroff handout and return precautions

— Vestibular neuritis: 2 weeks (assess steroid response, ambulation), 6 weeks (VRT progress); audiogram if any hearing complaint develops

— Ménière: every 3–6 months; track episode frequency, audiogram annually

— Vestibular migraine: 4–8 weeks to assess prophylaxis effect (full benefit at 2–3 months); headache diary review

— Post-stroke: 1 week post-discharge (med reconciliation), 1 month, 3 months, then per stroke clinic protocol

— Episode frequency, duration, severity (use validated scales — Dizziness Handicap Inventory, Vertigo Symptom Scale)

— Audiometry at baseline and serially for Ménière, schwannoma surveillance

— Fall log in elderly

— Medication side effects (especially anticholinergic burden, statin myopathy, antihypertensive orthostasis)

— Gaze stabilization exercises (VOR ×1, ×2) — promote central adaptation

— Habituation exercises — repeated exposure to provocative movements

— Balance and gait training — static and dynamic, eyes open/closed, foam surfaces

— Canalith repositioning when BPPV component present

— Duration: 6–8 weeks typical; home exercise program continues indefinitely for chronic deficits

— Reassure that central compensation occurs over weeks even with permanent unilateral vestibular loss

— Encourage early mobilization, not bed rest, after acute vestibular events

— Avoid chronic vestibular suppressants — explain they delay recovery

Board pearl: The single best long-term intervention for unilateral vestibular hypofunction is vestibular rehabilitation, not medication — this is a frequently tested Step 3 management answer.

Standard follow-up cadence:

Monitoring parameters:

Vestibular Rehabilitation Therapy (VRT) — core components:

Patient counseling pearls:

Return precautions: new neurologic deficit, severe headache, worsening despite treatment, new hearing loss, drop attacks — return to ED

Ethical, Legal, and Patient Safety Considerations

— Documentation must include HINTS exam results, gait assessment, and rationale for not imaging in low-risk patients

— Use shared decision-making for borderline cases — document the conversation

— Time-stamped notes matter for tPA/thrombectomy windows

— Counsel all vertigo patients to avoid driving, operating machinery, working at heights, or swimming alone during active symptoms

— Commercial drivers (CDL), pilots, mariners: regulatory reporting often required; obtain return-to-duty clearance from specialist

— Mandatory physician reporting of medically unsafe drivers varies by state (e.g., California, Oregon, Pennsylvania, Nevada have mandatory reporting); know your jurisdiction

— Epley maneuver: discuss expected nausea, brief vertigo intensification, neck precautions — verbal consent typically sufficient and documented

— Intratympanic gentamicin: written consent — risk of permanent hearing loss (intended vestibulotoxic effect carries cochlear collateral damage in 10–25%); document patient understanding

— Vestibular nerve section, labyrinthectomy: extensive consent, second opinion appropriate

— High-risk handoff: patient discharged with "peripheral vertigo" who hasn't yet declared as stroke — explicit return precautions, 48–72 hr follow-up appointment scheduled before discharge, written instructions in patient's preferred language

— Communicate findings clearly to specialists (Dix-Hallpike side, HINTS components, imaging done)

— Recurrent falls in cognitively intact patient — respect autonomy while documenting risk discussion, home safety recommendations, and offers of services

— Consider POLST/advance directives in frail elders after major event

— Vestibular PT availability varies; telehealth-delivered VRT is increasingly evidence-supported and improves access

— Audiology and MRI access disparities — advocate for timely referrals

Step 3 management: Before discharging a 70-year-old vasculopath labeled "peripheral vertigo," document HINTS exam, gait test, return precautions, scheduled 48-hour follow-up, and driving restriction — this five-element bundle is the defensible standard of care.

Missed posterior stroke = highest-liability vertigo error:

Driving and occupational safety:

Informed consent for procedures:

Transitions of care:

Elderly autonomy vs safety:

Equity and access:

High-Yield Associations and Rapid-Fire Clinical Facts

Board pearl: "Normal head impulse, direction-changing nystagmus, or skew deviation" = HINTS-central = stroke until imaged — memorize this triad cold for Step 3.

BPPV: posterior canal (85–90%), horizontal (10–15%), anterior (<2%); otoconia from utricle dislodge into canal

Dix-Hallpike positive nystagmus: upbeating + torsional toward dependent ear = ipsilateral posterior canal BPPV

Epley success rate: 80% first attempt, 90%+ after second; recurrence ~50% at 5 years

HINTS more sensitive than early MRI for posterior fossa stroke in acute vestibular syndrome — but only valid with continuous vertigo and nystagmus

Peripheral nystagmus: horizontal-torsional, unidirectional, suppresses with fixation, fatigable

Central nystagmus: vertical (especially down-beating), pure torsional, direction-changing, fixation-resistant

Ménière tetrad: episodic vertigo + fluctuating SNHL + tinnitus + aural fullness

Vestibular schwannoma: unilateral SNHL with poor word recognition out of proportion to pure-tone average → MRI IAC with gad; bilateral = NF2

Vestibular neuritis: post-viral, no hearing loss; steroids within 72 hr; labyrinthitis = neuritis + hearing loss

AICA stroke can mimic labyrinthitis (vertigo + ipsilateral SNHL) — vascular risk factors and central signs distinguish

PICA stroke = lateral medullary (Wallenberg) syndrome: vertigo, ipsilateral Horner, ipsilateral facial sensory loss, contralateral body sensory loss, dysphagia, hoarseness, ataxia

Top-shelf vertigo / rolling-in-bed vertigo = BPPV

Cough/Valsalva/loud-sound vertigo = superior canal dehiscence (Tullio phenomenon)

Drop attacks without LOC in Ménière = Tumarkin otolithic crisis

Aminoglycoside toxicity = bilateral vestibulopathy + oscillopsia; gentamicin > tobramycin > amikacin for vestibulotoxicity

Vertebral artery dissection: young patient, neck trauma/chiropractic manipulation, neck pain + posterior circulation symptoms

Benign paroxysmal vertigo of childhood = migraine equivalent, not BPPV

Vitamin D deficiency associated with recurrent BPPV

First-line vestibular migraine prophylaxis: propranolol, topiramate, amitriptyline, venlafaxine

Avoid chronic meclizine — delays compensation, falls in elderly (Beers)

Board Question Stem Patterns

— Answer: Epley (canalith repositioning) maneuver

— Distractors: meclizine daily, MRI, ENT referral

— Answer: MRI brain with DWI / admit for stroke workup (HINTS-central)

— Distractor: methylprednisolone for neuritis

— Answer: Low-sodium diet + HCTZ; audiometry confirms

— Answer: MRI internal auditory canal with gadolinium

— Answer: Propranolol or topiramate prophylaxis; trigger avoidance

— Answer: Lateral medullary (Wallenberg) syndrome / PICA stroke → stroke workup

— Answer: CTA neck, antithrombotic therapy

— Answer: CT temporal bone

— Answer: Valacyclovir + prednisone

— Answer: Discontinue meclizine, vestibular rehab, Dix-Hallpike

— Answer: Dix-Hallpike; if positive, Epley before return to play

Key distinction: When a stem includes vascular risk factors + spontaneous continuous vertigo, the test-makers want MRI/stroke workup, not symptomatic treatment — pattern-recognize this immediately.

Stem 1 — Classic BPPV: 62-year-old wakes with brief spinning when rolling in bed, lasts <30 seconds, no hearing loss; Dix-Hallpike reproduces symptoms with upbeating torsional nystagmus.

Stem 2 — Vestibular neuritis vs stroke: 70-year-old with HTN/DM has continuous vertigo for 12 hours, vomiting, normal head impulse, direction-changing nystagmus on lateral gaze.

Stem 3 — Ménière disease: 45-year-old with recurrent 2-hour vertigo episodes, low-pitch hearing loss, tinnitus, ear fullness.

Stem 4 — Vestibular schwannoma: 55-year-old with progressive unilateral hearing loss and disequilibrium; poor word recognition.

Stem 5 — Vestibular migraine: 32-year-old woman with recurrent vertigo + photophobia + headache, family history of migraine.

Stem 6 — Posterior circulation stroke: 68-year-old smoker with sudden vertigo, ipsilateral Horner, hoarseness, ipsilateral facial numbness, contralateral body numbness.

Stem 7 — Vertebral dissection: 35-year-old after chiropractic neck manipulation with severe neck pain and vertigo.

Stem 8 — Superior canal dehiscence: Patient with vertigo triggered by loud sounds (Tullio) and own voice (autophony).

Stem 9 — Ramsay Hunt: Vertigo + facial palsy + vesicles in ear canal.

Stem 10 — Elderly polypharmacy: 82-year-old on chronic meclizine for "dizziness" with falls and confusion.

Stem 11 — Post-concussion: Teen athlete with positional vertigo after football collision.

One-Line Recap

The Step 3 task in vertigo is to use timing/triggers (TiTrATE) and bedside tools — Dix-Hallpike for episodic positional vertigo, HINTS for acute continuous vertigo — to separate benign peripheral causes treatable in clinic (BPPV with Epley, neuritis with steroids and rehab, Ménière with salt restriction and HCTZ) from central red flags (posterior circulation stroke, cerebellar hemorrhage, schwannoma) that demand urgent imaging and escalation.

Board pearl: If you remember nothing else: brief + positional = Dix-Hallpike + Epley; continuous + spontaneous = HINTS + MRI; chronic unilateral hearing loss = MRI IAC — these three reflex pairings will answer the majority of Step 3 vertigo questions correctly.

Dix-Hallpike positive (upbeating torsional, fatigable) → Epley → follow-up in 1–2 weeks; this in-office sequence resolves the vast majority of BPPV cases and is the single highest-yield procedural skill on this topic

HINTS-central (normal head impulse, direction-changing nystagmus, or skew) → MRI with DWI and stroke workup, even when nystagmus looks "vestibular" and the patient is ambulatory — HINTS outperforms early MRI for posterior fossa infarcts

Vertigo + unilateral hearing loss narrows to four: labyrinthitis, Ménière, vestibular schwannoma, or AICA stroke; acute onset with vascular risk = image now, chronic progressive = MRI IAC with gadolinium

Avoid chronic vestibular suppressants (especially meclizine in elderly per Beers); they delay central compensation, cause falls, and are a frequent Step 3 wrong-answer trap — the durable interventions are canalith repositioning, vestibular rehabilitation, disease-specific therapy (steroids, diuretics, migraine prophylaxis), and aggressive vascular secondary prevention after stroke