32 year old women feeling giddiness . Stirring of head around 45 to 90 degree rotating head. Couldn’t lay down, and stand , nausea , 1 episode of vomiting , since 3 hours
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Clinical Assessment: 32-Year-Old Female with Positional Giddiness
Most Likely Diagnosis: Benign Paroxysmal Positional Vertigo (BPPV)
The presentation is classic:
- Vertigo triggered by head rotation (45-90 degree head movement)
- Difficulty lying down and standing (positional provocation)
- Nausea and vomiting (autonomic accompaniment)
- Acute onset, 3-hour duration
- Young woman (BPPV affects all ages, more common in women)
Pathophysiology
BPPV occurs due to canalolithiasis - free-floating otoconia (calcium carbonate crystals) that detach from the utricle and migrate into a semicircular canal (most commonly the posterior semicircular canal). Head movement sets these canaliths in motion, causing endolymph turbulence and abnormal deflection of the cupula, generating the sensation of vertigo.
- K.J. Lee's Essential Otolaryngology, p. 355
Diagnostic Criteria (Evidence-Based)
The following 4 criteria together have 88% sensitivity, 92% specificity (LR+ 11, LR- 0.13) for BPPV:
- Recurrent vertigo
- Duration of each attack < 1 minute
- Symptoms invariably provoked by changing head position (lying down, turning in bed, reclining, bending forward)
- Not attributable to another disorder
- Symptom to Diagnosis: An Evidence Based Guide, 4th Ed., p. 268
Confirm Diagnosis at Bedside: Dix-Hallpike Maneuver
Perform the Dix-Hallpike test: Move the patient from sitting to recumbent with the head tilted 30-45 degrees over the end of the table and 30-45 degrees to one side (test each ear separately).
Positive findings for BPPV (peripheral):
| Feature | BPPV (Peripheral) |
|---|---|
| Latency | 2-5 seconds |
| Duration of nystagmus | < 30 seconds (usually < 15 s) |
| Character | Mixed rotational-upward beating |
| Fatigue on repetition | Yes - fades after 3-4 repetitions |
| Direction on sitting up | Reverses |
- Adams and Victor's Principles of Neurology, 12th Ed., p. 353-354
- Symptom to Diagnosis, p. 268
Red Flags - Rule Out Central Cause
This patient MUST be evaluated for central vertigo (posterior circulation stroke/TIA) if any of the following are present:
- Nystagmus starts immediately (no latency), lasts > 1 minute, or does not fatigue
- Pure vertical nystagmus (not suppressed by fixation)
- Focal neurological signs (diplopia, dysphagia, dysarthria, limb ataxia, facial numbness)
- Severe unsteadiness - unable to sit or walk at all
- New severe headache ("thunderclap")
- Negative head impulse test (HINTS exam)
If red flags are present: Neurology consult + urgent MRI brain (MRI > CT for posterior fossa).
Management Algorithm
For this patient (triggered symptoms, no red flags):
1. Canalith Repositioning - Epley Maneuver (First-line)
- Involves 4-5 sequential head rotations, each held ~30 seconds (or until nystagmus/vertigo resolves)
- Effective in ~56-80% of patients with posterior canal BPPV
- Modified Epley reported up to 96.7% efficacy in some series
- The affected (dysfunctional) ear is the one that is downward when vertigo is elicited on Dix-Hallpike
A demonstration of both the Dix-Hallpike and Epley maneuvers:
2. Vestibular Suppressants (Symptomatic Relief)
- Since this patient is actively vomiting and cannot tolerate repositioning maneuvers, short-term vestibular suppressants are appropriate:
- Prochlorperazine (antiemetic/vestibular suppressant) - IV/IM for acute vomiting
- Meclizine (Antivert) - oral antihistamine
- Benzodiazepines (e.g., diazepam) - short-term only
- Caution: These drugs delay central CNS adaptation and should not be used long-term. They also worsen imbalance.
- Rosen's Emergency Medicine, p. 192
3. After Acute Episode
- Brandt-Daroff exercises - habituation exercises the patient can perform at home
- Semont liberatory maneuver - alternative to Epley
- Horizontal canal BPPV (if Dix-Hallpike negative): "Barbecue roll" or Gufoni maneuver
Differential Diagnosis to Consider
| Disorder | Duration of Vertigo | Key Distinguishing Feature |
|---|---|---|
| BPPV (most likely) | Seconds (< 1 min) | Purely positional, no hearing loss, fatigable nystagmus |
| Vestibular neuritis | Days to weeks | Spontaneous, continuous vertigo; no hearing loss |
| Meniere's disease | Minutes to hours | Fluctuant sensorineural hearing loss, tinnitus, aural fullness |
| Cerebellar/brainstem stroke | Constant/progressive | Neurological signs, cannot walk, no fatigue of nystagmus |
| Vestibular migraine | Variable | Headache history, migrainous features |
- K.J. Lee's Essential Otolaryngology, p. 356
Natural History
Most cases of BPPV resolve spontaneously within 2-6 weeks (sometimes months). About half of patients have recurrent clusters. Surgical options (posterior canal occlusion, singular neurectomy) exist for refractory cases but are rarely needed.
Summary of Immediate Action Plan
- Neurological exam - rule out focal deficits (HINTS exam if continuous vertigo)
- Dix-Hallpike maneuver - confirm BPPV, identify affected ear
- IV/IM antiemetic (prochlorperazine or ondansetron) for active vomiting
- Epley maneuver once patient can tolerate it
- If atypical features or unable to walk - MRI brain to exclude posterior fossa lesion
- Reassure and follow up; prescribe home Brandt-Daroff exercises on discharge
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