A 33-year-old man presents to the emergency department with dizziness. He states he has a constant sensation that the room is spinning. He is now having trouble walking and has been vomiting intermittently. He has no past medical history and takes no medications. His temperature is 98.0°F (36.7°C), blood pressure is 122/84 mmHg, pulse is 80/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam reveals a young man who is vomiting. His gait is ataxic and he exhibits rightward nystagmus. His dizziness is constant and unchanged with performance of the Dix-Hallpike maneuver. The head impulse test reveals a corrective saccade and there is no skew deviation. Which of the following is the most appropriate next step in management?
Prednisone
Epley maneuver
MRI brain
CT head
Prednisone
This young, healthy patient is presenting with constant vertigo, ataxia, vomiting, and a head impulse test revealing a corrective saccade, nystagmus, and test of skew (HINTS) exam, which suggests a peripheral etiology of vertigo, most likely vestibular neuritis. As the diagnosis can be made clinically, steroids are the only treatment needed.

Differentiating peripheral (the vestibular system) versus central (the brain) vertigo is critical in management. Peripheral vertigo is commonly caused by benign paroxysmal positional vertigo, vestibular neuritis, and labyrinthitis. Vertigo that is constant is more consistent with vestibular neuritis or labyrinthitis but could also be a cerebellar stroke. To differentiate, age, risk factors, and onset of symptoms are critical. Moreover, the HINTS exam can point toward 1 cause of vertigo versus another. HINTS is a mnemonic for: Horizontal head impulse testing (Head Impulse), Direction-changing nystagmus in eccentric gaze (Nystagmus), and Vertical skew (Test of Skew). Findings that are suggestive of a peripheral cause of vertigo include a positive head impulse exam, positive nystagmus (also seen in stroke), and a negative test of skew. In the appropriate clinical context with appropriate risk factors, peripheral causes such as vestibular neuritis or labyrinthitis can be managed with steroids (which may improve outcomes) and meclizine (for symptom control).

Kattah et al. discuss the HINTS exam. They note how it can be used to differentiate peripheral from central vertigo. It is recommended to perform this exam when differentiating central versus peripheral vertigo.

Incorrect Answers:
Answers 1 & 3: Head imaging such as a CT head or MRI brain is not necessary in patients with a clear peripheral cause of their vertigo/dizziness with a HINTS exam suggesting a peripheral etiology. Clinically, this patient has vestibular neuritis and can be treated accordingly. Imaging would be needed if the patient had an acute cerebellar stroke.

Answer D: The Epley maneuver is only indicated in cases of benign paroxysmal peripheral vertigo, which presents with severe vertigo (with changes in head position) that diminish with time and keeping the head stationary. Note that this patient’s Dix-Hallpike maneuver is negative and that his vertigo is constant rather than intermittent or positional.

Answer E: Tissue plasminogen activator is indicated within 4.5 hours in the setting of an ischemic stroke after a head CT rules out a head bleed, other reversible causes are treated, and assuming there are no contraindications to thrombolytics. Tissue plasminogen activator can be given in posterior circulation strokes.

Bullet Summary:
Peripheral causes of vertigo generally do not require head imaging, and causes such as labyrinthitis or vestibular neuritis can be treated with steroids.