Benign paroxysmal positional vertigo: A practical approach for emergency physicians

Abstract

Benign paroxysmal positional vertigo (BPPV) is a very common condition in the population and an important cause of acute vertigo or dizziness in patients presenting to an emergency department (ED). Despite this, abundant evidence shows that current ED management of patients with BPPV is suboptimal. Common ED management processes include brain imaging and treatment with vestibular suppressant medications such as meclizine, neither of which is recommended by current guidelines. The most efficient management of BPPV is to perform a bedside test (Dix‐Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver. In this practical review we emphasize the efficient management for the most common form of BPPV—posterior canal BPPV. Using this management will reduce resource utilization (laboratory testing, brain imaging, specialist consultation), reduce ED length of stay, and reduce use of ineffective mediations that have side effects but little therapeutic effect. Application of these practices would improve important patient‐centered outcomes such as symptom reduction, radiation exposure, side effects from medications, and less need for urgent follow‐up with another health care provider. The article also discusses the approach to patients in whom the Dix‐Hallpike and/or Epley maneuvers do not seem to work. This includes a discussion the second most common variant of BPPV (horizontal canal BPPV) and criteria for safe discharge of patients. Another important advantage of learning BPPV best practices is that it is enormously satisfying for the clinician, not unlike treating a child with a nursemaid's elbow.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

“…Routine use of the Dix–Hallpike test by emergency clinicians is very low, 70,71,75,106 and incorrect interpretation of nystagmus findings is common 181,225 . It is important to note that the Dix–Hallpike test is the preferred test for pc‐BPPV and not for other types of BPPV; however, some patients with hc‐BPPV will have horizontal nystagmus with Dix–Hallpike testing 148 . Nystagmus on Dix–Hallpike testing can also be negative in patients with hc‐BPPV and in patients with so‐called “subjective” BPPV (i.e., positional vestibular symptoms without nystagmus).…”

“…However, we do not recommend use of these medications as the primary treatment for patients with BPPV. As discussed, we encourage clinicians to consider hc‐BPPV in patients whose histories suggest BPPV but whose Dix–Hallpike test either is negative or shows horizontal nystagmus; if properly trained and comfortable with the diagnosis, clinicians should treat hc‐BPPV in the ED 148 …”

“…However, very early in the course of BPPV, some patients describe lingering interictal symptoms probably due to longer lasting nausea or anxiety about moving the head normally, superficially mimicking an AVS. In such patients, assuming there is no spontaneous or direction‐changing gaze‐evoked nystagmus, it is reasonable to perform the Dix–Hallpike test 148 . In this situation, it is important to strictly interpret the Dix–Hallpike test results—a positive being the reproduction of symptoms plus transient, crescendo–decrescendo, upbeat–torsional nystagmus with torsion toward the affected ear on one side only.…”

“…The recently completed AVERT trial (NCT02483429), which used the most rigorous diagnostic methods in any ED‐based trial to date, found that among 43 BPPV patients, 20 had pc‐BPPV, 16 had hc‐BPPV, and seven had other variant forms (including multicanal BPPV) 181 . We encourage clinicians to consider hc‐BPPV in patients whose histories suggest BPPV but whose Dix–Hallpike test is either negative or shows horizontal nystagmus 148 . The specific diagnostic maneuver for hc‐BPPV is the supine roll test and the corresponding therapeutic maneuver is the Lempert (barbeque) roll 67 .…”

Insights into Benign Paroxysmal Positional Vertigo in the Elderly

“…The lateral recumbency test is an alternative diagnostic test that involves the following steps (24): place the patient in a starting neutral position, turn the patient's head rapidly to the right, check for characteristic nystagmus, return the head to a face-up position, and allow the nystagmus all subsided, then a quick turn to the left to check for nystagmus again, which can be used in patients who cannot use the Dix-Holpike method, but is much less sensitive.…”