BPPV in the ED: off balance

-Case-

A 54-year-old woman comes to the ED after nearly falling out of bed that morning. She reports a sudden, intense spinning sensation when she rolled over, lasting less than a minute. She feels better sitting upright but gets dizzy again when she turns her head to the right. No hearing loss, tinnitus, headache, or recent illness are noted; she’s steady on her feet now but terrified to move her head. How do we get them back on their feet?

-Evaluation-

This classic story? It screams benign paroxysmal positional vertigo (BPPV). BPPV is one of the most common causes of peripheral vertigo in the ED. A majority of these cases are from loose otoliths (calcium carbonate crystals) that get dislodged from the utricle and migrate into the semicircular canals (most commonly the posterior canal). When the head changes position, those particles slosh around, sending confusing signals to the brain, resulting in vertigo.

Key features:

• Sudden, brief episodes of vertigo (lasting seconds to a minute)
• Triggered by changes in head position (rolling over, looking up)
• No hearing loss, tinnitus, or neurological deficits

To diagnose it, try the Dix-Hallpike maneuver:

• Have the patient sit upright, turn their head 45 degrees to one side, and quickly lie back with the head hanging off the bed
• A positive test elicits vertigo and a characteristic torsional nystagmus

If the patient has hearing loss, persistent vertigo not related to position, or neuro findings, you need to look for other central causes (e.g., cerebellar stroke, vestibular migraine). This prompts a full neuro workup!

-Management-

The first-line treatment for BPPV is not medication – it’s repositioning maneuvers, like the Epley maneuver:

• The Epley maneuver helps guide the rogue otoliths back into the utricle where they belong.
• It works best for posterior canal BPPV and can be performed at the bedside.
• Have antiemetics on hand; this can make patients pretty nauseated.
• Benzos and antihistamines (meclizine) are generally not necessary unless severe symptoms prevent testing or treatment.

If symptoms persist despite proper maneuvers, an outpatient ENT referral is reasonable.

-Fast Facts-

• BPPV is the most common peripheral vertigo in the ED
• It presents with brief, positional episodes of vertigo without hearing symptoms or neuro deficits
• Diagnosed with Dix-Hallpike and treated with Epley maneuver
• Avoid unnecessary imaging unless there are red flags!

Don’t let vertigo throw you for a spin – if the story fits and there’s no neuro drama, a quick bedside maneuver can stop the world from spinning.

Want to learn more? Read our in-depth study guide and listen to our podcast episodes on this topic!

Cheers,

Tamir Zitelny, MD

-References-

1. Kerber KA, Meurer WJ, West BT, et al. Dizziness presentations in U.S. emergency departments, 1995–2004. Acad Emerg Med. 2008;15(8):744–50. doi:10.1111/j.1553-2712.2008.00189.x
2. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: Benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. doi:10.1177/0194599816689667
3. Newman-Toker DE, Hsieh YH, Camargo CA, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83(7):765-75. doi:10.4065/83.7.765
4. von Brevern M, Seelig T, Radtke A, et al. Short-term efficacy of Epley’s manoeuvre: a double-blind randomised trial. J Neurol Neurosurg Psychiatry. 2006;77(8):980-2. doi:10.1136/jnnp.2005.085886
5. Saber Tehrani AS, Coughlan D, Hsieh YH, et al. Rising annual costs of dizziness presentations to U.S. emergency departments. Acad Emerg Med. 2013;20(7):689-96. doi:10.1111/acem.12168