Review Article

Primary Evaluation and Acute Management of Vertigo

Sisha Liz Abraham
Department of Surgical Oncology, Cochin Cancer Research Centre, Kochi, Kerala, India
Downloaded from http://journals.lww.com/cmii by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

Abstract
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/18/2024

Vertigo, an illusory movement, arises mostly because of lesions in the peripheral vestibular system (e.g., damage or dysfunction of the labyrinth and
vestibular nerve) and occasionally that of central vestibular structures. Patients give various descriptions of vertigo: a head‑spinning feeling, swaying,
tilting, or an imbalance in walking depending on the location of the lesion. Acute vertigo remains a diagnostic challenge for the physicians due to the
wide array of differential diagnosis. It is important to distinguish the central causes of vertigo from its peripheral causes. Benign paroxysmal positional
vertigo (BPPV) is one of the most common causes of peripheral vertigo, most commonly attributed to calcium debris within the posterior semicircular
canal, known as canalithiasis. Prompt diagnosis by positional testing (e.g., Dix–Hallpike), performing a bedside repositioning maneuver (e.g., Epley)
and administering symptomatic therapy helps in providing the quick relief to the highly distressing symptom of vertigo due to BPPV.

Keywords: Benign paroxysmal positional vertigo, Epley maneuver, peripheral vertigo, vertigo

Address for correspondence: Dr. Sisha Liz Abraham, Department of Surgical Oncology, Cochin Cancer Research Centre, Kochi, Kerala, India.
E‑Mail: sisha.liz@gmail.com

Introduction
Vertigo is a symptom of illusory movement (feels as if the person or the objects around them are moving when they are not). It
arises because of abnormalities in the peripheral vestibular system (e.g., damage to/dysfunction of the components of labyrinth
and vestibular nerve) or from the lesions of the central vestibular structures in the brainstem.[1‑3] It is associated with significant
disability and can be prolonged or intermittent in nature. Vertigo, as a symptom, poses a significant challenge to emergency care
physicians as they have to consider a wide array of differential diagnosis in a short span of time and localize the lesion [Table 1].
Hence, a prompt and timely diagnosis is essential to initiate any early intervention that is required.
Vertigo is a symptom and not a diagnosis. Patients varyingly describe it as a head‑spinning feeling, swaying, tilting, or an
imbalance in walking depending on the exact site of abnormality.[4‑6] The most common sensation is a rotatory sensation, though
it is not always the case. Vertigo can occur as a single or recurrent episode and may last seconds, hours, or days. Acute vertigo
may be associated with nausea and vomiting, which may be significant enough to cause dehydration and electrolyte imbalance.
A summary of the clinical features of common forms of acute vertigo is shown in Table 2.
The evaluation of a patient with vertigo is shown in Figure 1.

Evaluation: History
A history of the symptoms plays a key role in distinguishing vertigo from the other differentials and in localizing the lesion.
Try to obtain an unprompted description of the patient’s “dizziness” or “giddiness.” Cardiovascular causes usually lead to

Date of Submission: 08‑Feb‑2020 Date of Review: 09-Feb-2020

Date of Acceptance: 04-Mar-2020 Date of Web Publication: 10-Jul-2020

Access this article online This is an open access journal, and articles are distributed under the terms of the Creative
Quick Response Code: Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
Website: remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
www.cmijournal.org is given and the new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI:
10.4103/cmi.cmi_11_20 How to cite this article: Abraham SL. Primary evaluation and acute
management of vertigo. Curr Med Issues 2020;18:217-21.

© 2020 Current Medical Issues | Published by Wolters Kluwer - Medknow 217

 Abraham: Primary management of vertigo and BPPV

presyncope/syncope and neurological causes are accompanied
by disequilibrium. Hence, both should be ruled out during the
Table 1: Common causes of central and peripheral vertigo
Peripheral causes Central causes
Benign paroxysmal positional vertigo Vestibular migraine
Downloaded from http://journals.lww.com/cmii by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
evaluation in emergency care. A good history should include
the following:
• Time course of events:
• Recurrent vertigo of short duration with positional
variation suggests benign paroxysmal positional
vertigo (BPPV) whereas that of long duration
suggests Meniere’s disease[7,8]

Vestibular neuritis Brainstem ischemia • A single episode of vertigo lasting many hours may
Meniere’s disease Cerebellar infarction point to migraine or transient ischemic attack of the
and hemorrhage brain stem[9]
Herpes zoster oticus Head trauma • Labyrinthitis and vestibular neuronitis are typically
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/18/2024

Labyrinthine concussion associated with the vertigo of prolonged duration over

Otitis media days.[10,11]

Table 2: Clinical features of common causes of vertigo[3]

Time course Suggestive clinical Associated Auditory symptoms Other diagnostic
setting neurologic symptoms features
Benign paroxysmal Recurrent, brief(s) Predictable head None None Dix‑Hallpike
positional vertigo movement/positions maneuver is
precipitate symptoms diagnostic
Vestibular neuritis Single episode, acute History of or Falls toward the side Usually none Head thrust test
onset, lasts days accompanying viral of the lesion, no usually abnormal
syndrome brainstem signs
Meniere’s disease Recurrent episodes, Spontaneous onset None May be preceded by Audiometry shows
last min‑several hours ear pain, U/L hearing U/L sensorineural
loss, tinnitus hearing loss
Vestibular migraine Recurrent episodes, History of migraine Migraine headache Usually none Between episodes,
(peripheral/central last several minutes and/or other tests are usually
nystagmus) to hours migrainous symptoms normal
Abhilash[3]

Figure 1: Evaluation of a patient with vertigo.

218 Current Medical Issues ¦ Volume 18 ¦ Issue 3 ¦ July‑September 2020

 Abraham: Primary management of vertigo and BPPV
• Aggravating and relieving factors: All types of vertigo
become symptomatically worse with the head movement.
Most patients prefer to keep their head still in fear
of worsening of symptoms. Vertigo aggravated by or
provoked with specific head movements or postures is
typical of BPPV. History of head trauma should always
be sought for the likely possibility of whiplash or that
Downloaded from http://journals.lww.com/cmii by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
of perilymphatic fistula.[12] History of vertigo and a
recent viral infection suggest the possibility of vestibular
neuronitis caused by the inflammation of the eighth cranial
nerve[11]
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/18/2024
• Associated symptoms: The features of the brain stem
involvement such as diplopia, dysarthria, dysphagia,
weakness, or numbness suggest vertigo due to a
vertebrobasilar stroke. Peripheral vertigo associated with
the symptoms such as deafness and tinnitus may point to
Meniere’s disease. Headache and photophobia are usually
associated with migrainous vertigo[9]
• Past medical history: A significant past medical history
includes a history of migraine, risk factors for a
cerebrovascular accident (diabetes mellitus, hypertension,
smoking, etc.), other neurological disorders, status
of vision, psychiatric issues, and past history of head
trauma. Certain medications (aminoglycosides, cisplatin,
and phenytoin) can cause vertigo, and drug history is
absolutely essential.[13]
Evaluation: Examination
It is important to perform a complete otologic and neurologic
examination in patients presenting with vertigo.
• Nystagmus: It is a rhythmic oscillation of the eyes. The
patient with the acute onset of vertigo tends to have
nystagmus when the gaze is not fixed. In peripheral
vertigo, the fast phase is usually away from the affected
side. Peripheral vertigo is characterized by horizontal or
torsional or mixed nystagmus, but never vertical. Central
vertigo may have any trajectory, but vertical nystagmus
strongly suggests a central origin of vertigo
• Other neurological signs: A detailed central nervous
system exami nation look i ng for cranial ner ve
abnormalities, cerebellar signs, motor or sensory
changes, or abnormal reflexes, which would indicate a
central cause for vertigo
• Tests of hearing: Bedside tests of hearing (Weber and
Rinne tests) and an otoscopic examination of the tympanic
membrane for evidence acute or chronic otitis media. It
should be performed to distinguish the etiology of vertigo
• Dix‑Hallpike maneuver: The most important cause of
vertigo that present as an acute emergency is BPPV. This
maneuver is helpful in diagnosing the classical posterior
canal BPPV. It should not be performed in patients
with a carotid bruit or risk factors for vertebrobasilar
insufficiency due to a theoretical risk of precipitating a
cerebrovascular accident.[14,15] The test is diagnostic for
BPPV if positive, but does not rule it out if negative.
Current Medical Issues ¦ Volume 18 ¦ Issue 3 ¦ July‑September 2020
Benign Paroxysmal Positional Vertigo
BPPV is one of the most common causes of vertigo presenting
in the emergency department. It is a mechanical disorder of
the inner ear and is commonly attributed to free‑floating debris
within the semicircular canal (posterior being the most common),
known as canalithiasis.[16‑18] This debris likely represents loose
otoconia (calcium carbonate crystals) within the auricular sac.
These are normal structures that are displaced from the utricle.
There are three variants:
• Posterior canal (prototype/classical) – the most common
• Horizontal canal (lateral canal) – the second‑most
common
• Anterior canal (superior canal).
Posterior Canal Benign Paroxysmal Positional
Vertigo (Proto‑Type/Classical)
Recurrent episodes of vertigo lasting 1 min or less. Although
individual episodes are brief, these typically recur periodically
for weeks to months without therapy. Episodes are provoked by
the specific types of head movements, such as looking up while
standing or sitting, lying down or getting up from bed, and
rolling over in bed. The spells may wax and wane over time.
Vertigo may be associated with nausea and at times vomiting.
Examination
Nystagmus is optimally provoked by the Dix–Hallpike or
Nylen–Barany maneuver (sensitivity 50%–88%).[14] Nystagmus
is an involuntary movement of the eye characterized by a
smooth pursuit eye movement followed by a rapid saccade in
the opposite direction of the smooth pursuit eye movement.
Dix–Hallpike maneuver is helpful in diagnosing the classical
posterior canal BPPV. The test itself may provoke severe
vertigo. Premedication with betahistine or dimenhydrinate IM
or IV may make the test more tolerable and will not diminish
the nystagmus.
Dix‑Hallpike maneuver
• Instruct the patient to keep their eyes open all the time
and look at the examiners face
• With the patient sitting, extend the neck and turn to one
side
• Place the patient supine rapidly, so that the head hangs
over the edge of the bed
• Keep the patient in this position until 30 s have passed if
no nystagmus occurs
• The patient should also be queried about the presence of
subjective vertigo
• Return the patient to upright position, observe for another
30 s for nystagmus, and then repeat the maneuver with
the head turned to the other side.
Diagnostic criteria employing the Dix–Hallpike maneuver
for posterior canal benign paroxysmal positional vertigo
• Nystagmus and vertigo usually appear with a latency of
a few seconds and last <60 s
219
 Abraham: Primary management of vertigo and BPPV

• It has a typical trajectory, beating upward and torsionally,

with the upper poles of the eyes beating toward the ground
with a crescendo‑decrescendo pattern
• After it stops and the patient sits up, the nystagmus may
recur but in the opposite direction
• The patient should then have the maneuver repeated to the
same side, with each repetition, the intensity and duration
Downloaded from http://journals.lww.com/cmii by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
Table 3: Particle repositioning maneuver (Epley maneuver)
Epley maneuver for the right side BPPV
Step 1: The patient seated with head erect and facing forward
Step 2: The head is turned toward 45° to the right, and the patient is
moved rapidly into a supine position with head extending just beyond
examining table (45° to horizontal), right ear down

of nystagmus will diminish.(nystagmus fatigability) Step 3: Examiner moves to head end of the table
• The side showing the positive test is the side of the lesion. Step 4: Head is quickly rotated to the left side. Right ear upward
(90° to the left). This position is held for 30 s
The clinical practice guideline published by the American
Step 5: The patient rolls into the left side while the examiner rapidly rotates
Academy of Otolaryngology and Head and Neck Surgery
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/18/2024

head until the nose is angled toward the floor. This position is held for 30 s
does not include nystagmus fatigability as a diagnostic
Step 6: The patient is rapidly lifted into the sitting position
criterion.[19] If the patient’s history is compatible with BPPV,
but the Dix–Hallpike test exhibits no nystagmus or horizontal
nystagmus, and the clinician should perform a supine roll test
to assess for lateral semicircular canal BPPV.
Supine head roll test (Pagnini‑Lempert or Pagnini‑McClure
Roll test) for lateral canal benign paroxysmal positional
vertigo
• The patient is made to lie supine with the head in the
neutral position, followed by quickly rotating the head
90° to one side
• The patient’s eyes are observed for nystagmus
• Once the nystagmus subsides or if no nystagmus is
elicited, the head is then brought back to the straight face
up supine position
• If any additional nystagmus is elicited, it is allowed
to settle and the head is then quickly turned 90° to the
opposite side, and the eyes are once again observed for
Figure 2: Epley maneuver. The patient is instructed to lie supine or to left
nystagmus.
with the head elevated after the procedure and be preferably on bed rest
Lateral semicircular canal BPPV may occur following the after the procedure for 48 h. The entire sequence is repeated later for
performance of the canalith repositioning procedure for residual symptoms. BPPV: Benign paroxysmal positional vertigo
an initial diagnosis of posterior semicircular canal BPPV
(canal conversion). Hence, clinicians should be aware of lateral Commonly used medications for vertigo
semicircular canal BPPV and its diagnosis.[20] • Tablet cinnarizine 25 mg three times a day OR
• Tablet betahistine 16 mg three times a day OR
Acute Management of Benign Paroxysmal • Tablet prochlorperazine 10 mg three times a day OR
• Tablet flunarizine 10 mg three times a day OR
Positional Vertigo • Tablet promethazine 25 mg twice a day OR
The particle repositioning maneuver (Epley maneuver more • Syrup diphenhydramine 10–20 ml three times a day.
commonly practiced than Semont maneuver) should be
performed for all patients with confirmed posterior canal BPPV. These drugs are quite effective for acute symptomatic relief
The Epley maneuver for a right side BPPV is shown in Table 3 of vertigo. Antihistamines are usually used as the first choice
and Figure 2. This procedure alone provides significant symptom for most patients, with sedation being a common side effect.
relief in many patients.[21,22] Lempert 360 roll maneuver or The phenothiazine antiemetics such as prochlorperazine and
Gufoni maneuver is performed for lateral canal BPPV. promethazine are more sedating and hence are reserved for
patients with severe vomiting. Benzodiazepines too are quite
Oral medications may then be added for additional symptomatic sedative and are reserved for patients with severe symptoms.
management. The following classes of drugs are effective in The drug of choice in pregnancy is meclizine.[23]
suppressing the vestibular system.
• Antihistamines: diphenhydramine, dimenhydrinate,
cinnarizine, and meclizine Conclusion
• Antiemetics: prochlorperazine, promethazine, ondansetron, Acute vertigo remains a diagnostic challenge for emergency
and metoclopramide physicians due to the wide array of differential diagnosis.
• Benzodiazepines: diazepam, lorazepam, and alprazolam. It may be categorized as central or peripheral and making

220 Current Medical Issues ¦ Volume 18 ¦ Issue 3 ¦ July‑September 2020

 Abraham: Primary management of vertigo and BPPV
the distinction between the two is the most important part
of evaluation. A thorough history is important to distinguish
vertigo from other forms of giddiness or lightheadedness.
Laboratory testing and radiography are not routinely indicated
in the workup of patients with vertigo when no other neurologic
abnormalities are present. Prompt diagnosis, performing a
bedside canalith repositioning maneuver, and administering
Downloaded from http://journals.lww.com/cmii by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
symptomatic therapy help in quick relief in BPPV which
happens to be the most common cause of vertigo.
Financial support and sponsorship
Nil.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 01/18/2024
Conflicts of interest
There are no conflicts of interest.
References
1. Neuhauser HK. Epidemiology of vertigo. Curr Opin Neurol
2007;20:40‑6.
2. Norrving B, Magnusson M, Holtås S. Isolated acute vertigo in the
elderly; vestibular or vascular disease? Acta Neurol Scand 1995;91:43‑8.
3. Abhilash KP. Emergency Medicine: Best Practices at CMC. 2nd ed., Ch.
87, 282. New Delhi: Jaypee Brothers’ Medical Publishers; 2019.
4. Newman‑Toker DE, Cannon LM, Stofferahn ME, Rothman RE,
Hsieh YH, Zee DS. Imprecision in patient reports of dizziness symptom
quality: A cross‑sectional study conducted in an acute care setting.
Mayo Clin Proc 2007;82:1329‑40.
5. Stanton VA, Hsieh YH, Camargo CA Jr., Edlow JA, Lovett PB,
Goldstein JN, et al. Overreliance on symptom quality in diagnosing
dizziness: Results of a multicenter survey of emergency physicians.
Mayo Clin Proc 2007;82:1319‑28.
6. Nedzelski JM, Barber HO, McIlmoyl L. Diagnoses in a dizziness unit.
J Otolaryngol 1986;15:101‑4.
7. Karlberg M, Hall K, Quickert N, Hinson J, Halmagyi GM. What
inner ear diseases cause benign paroxysmal positional vertigo? Acta
Otolaryngol 2000;120:380‑5.
8. Epley JM. New dimensions of benign paroxysmal positional vertigo.
Otolaryngol Head Neck Surg (1979) 1980;88:599‑605.
9. Neuhauser H, Leopold M, von Brevern M, Arnold G, Lempert T. The
interrelations of migraine, vertigo, and migrainous vertigo. Neurology
Current Medical Issues ¦ Volume 18 ¦ Issue 3 ¦ July‑September 2020
2001;56:436‑41.
10. Schessel DA, Minor LB, Nedzelski J. Meniere’s disease and other
peripheral vestibular disorders. In: Gaertner RS, Murphy MB,
editors. Cummings Otolaryngology Head and Neck Surgery. 4th ed.,
Philadelphia: Mosby; 2004. p. 3231‑2.
11. Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med
2003;348:1027‑32.
12. Black FO, Pesznecker S, Norton T, Fowler L, Lilly DJ, Shupert C, et al.
Surgical management of perilymphatic fistulas: A Portland experience.
Am J Otol 1992;13:254‑62.
13. Cianfrone G, Pentangelo D, Cianfrone F, Mazzei F, Turchetta R,
Orlando MP, et al. Pharmacological drugs inducing ototoxicity,
vestibular symptoms and tinnitus: A reasoned and updated guide. Eur
Rev Med Pharmacol Sci 2011;15:601‑36.
14. Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis
of certain common disorders of the vestibular system. Ann Otol Rhinol
Laryngol 1952;61:987‑1016.
15. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre
for benign paroxysmal positional vertigo. Cochrane Database Syst Rev
2014;(12):CD003162.
16. Brandt T, Steddin S. Current view of the mechanism of benign
paroxysmal positioning vertigo: Cupulolithiasis or canalolithiasis? J
Vestib Res 1993;3:373‑82.
17. Vannucchi P, Giannoni B, Pagnini P. Treatment of horizontal semicircular
canal benign paroxysmal positional vertigo. J Vestib Res 1997;7:1‑6.
18. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign
paroxysmal positional vertigo (BPPV). CMAJ 2003;169:681‑93.
19. Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El‑Kashlan H,
Fife T, et al. Clinical Practice Guideline: Benign Paroxysmal Positional
Vertigo (Update). Otolaryngol Head Neck Surg 2017;156:S1‑S47.
20. White JA, Coale KD, Catalano PJ, Oas JG. Diagnosis and management
of lateral semicircular canal benign paroxysmal positional vertigo.
Otolaryngol Head Neck Surg 2005;133:278‑84.
21. Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle
repositioning maneuvers in the treatment of benign paroxysmal
positional vertigo: A systematic review. Phys Ther 2010;90:663‑78.
22. Strupp M, Cnyrim C, Brandt T. Vertigo and dizziness: Treatment
of benign paroxysmal positioning vertigo, vestibular neuritis
and Menère’s disease. In: Candelise L, editor. Evidence‑Based
Neurology‑Management of Neurological Disorders. Oxford: Blackwell
Publishing; 2007. p. 59‑69.
23. Leathem AM. Safety and efficacy of antiemetics used to treat nausea and
vomiting in pregnancy. Clin Pharm 1986;5:660‑8.
221