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ent.bppv.core.v1PRODUCTION
ent.bppv.core.v1

Benign paroxysmal positional vertigo (with acute-vertigo triage)

general_internal_medicineacutesubacuteadultgeriatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame the encounter as a TWO-CHANNEL problem: positively diagnose + definitively repositioning-treat BPPV (the commonest peripheral vertigo) AND robustly exclude the dangerous central look-alikes. The explicit peripheral-vs-central decision is the spine of this engine. Definitive stroke/neuritis/Ménière/migraine/falls management is routed OUT by engine_id, not re-authored.

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two-channel scope confirmed; out-of-scope definitive management flagged for engine_id routing

Patient inputs (16)

TiTrATE pivot 2 — vertigo OBLIGATELY provoked by head-position change (not merely worse with movement) defines triggered-episodic vestibular syndrome and is the BPPV gateway (Bárány Society criteria, von Brevern 2017)

BPPV paroxysms last <1 min (typically 10-30 s) and fatigue; spells of minutes-hours-days argue Ménière / vestibular migraine / AVS (Bárány Society criteria; von Brevern JNNP 2006 — median episode 2 wk of recurrent brief spells)

Age, HTN, DM, AF, smoking, prior stroke/TIA, recent neck trauma/manipulation (vertebral dissection) raise the pre-test posterior-circulation-stroke prior in AVS and lower the imaging threshold (von Brevern JNNP 2006 — HTN/stroke independently associated; Kattah 2009)

BPPV incidence rises steeply with age; elderly BPPV drives falls/fracture risk and modifies maneuver choice (cervical/vascular limits) and disposition (AAO-HNS BPPV CPG 2017 — fall-risk modifier; von Brevern JNNP 2006)

TiTrATE pivot 1 — episodic (seconds, recurrent, triggered) → BPPV channel; continuous (hours-days, spontaneous) → AVS channel where HINTS, not Dix-Hallpike, governs (Newman-Toker Neurol Clin 2015 TiTrATE)

Up-beating + torsional (geotropic, top-pole toward affected/down ear) nystagmus with latency, crescendo-decrescendo, <1 min, fatigability = posterior-canal BPPV; persistent / pure-vertical / pure-torsional / direction-fixed downbeat raises central mimic (AAO-HNS BPPV CPG 2017; Bárány 2017)

In AVS: a NORMAL (no corrective saccade) horizontal head-impulse is the single most ominous HINTS element — points central/stroke (an abnormal/positive HIT supports peripheral vestibular neuritis) (Kattah Stroke 2009 — HINTS 100% sens / 96% spec for stroke)

Direction-CHANGING gaze-evoked or pure-vertical/torsional nystagmus = central; unidirectional horizontal-torsional fixation-suppressible nystagmus = peripheral (Kattah Stroke 2009; Newman-Toker AEM 2013)

Vertical ocular misalignment on alternate cover (skew deviation) = brainstem/central; present in ~17% and rescues the false-localising abnormal head-impulse (Kattah Stroke 2009 — skew predicts brainstem)

The 4 D's (diplopia, dysarthria, dysphagia, dysmetria), severe truncal/gait ataxia (cannot stand/walk unaided), limb ataxia, new severe headache/neck pain → posterior-circulation stroke until excluded; route OUT (AAO-HNS BPPV CPG 2017; Kattah Stroke 2009)

If Dix-Hallpike negative/non-diagnostic but history compatible: supine roll (Pagnini-McClure) — geotropic horizontal nystagmus = canalolithiasis, apogeotropic = cupulolithiasis; identifies horizontal-canal BPPV (~5-15%) (AAO-HNS BPPV CPG 2017 Recommendation; Bárány 2017)

New unilateral hearing loss / tinnitus / aural fullness → Ménière or AICA-territory stroke or SSNHL (HINTS "plus" — any new hearing loss in AVS raises central/AICA risk) — route to ENT/SSNHL engine (Newman-Toker AEM 2013 HINTS-plus; Bárány)

Migraine history + episodic spontaneous vertigo (± photophobia/aura) suggests vestibular migraine — the commonest central episodic mimic and frequently comorbid with BPPV (Eggers J Vestib Res 2014 — BPPV/Ménière/motion-sickness over-represented in migraineurs)

Severe persistent vomiting/inability to tolerate oral intake → short-term parenteral antiemetic + rehydration and admission threshold; also a marker of a more severe vestibular insult or central cause (AAO-HNS BPPV CPG 2017; clinical)

Severe cervical spondylosis/RA/instability, carotid disease or vertebral compromise limit Dix-Hallpike/Epley neck extension-rotation → use side-lying (Semont) or modified maneuvers (Hilton Cochrane 2014 — cervical-spine intolerance noted; AAO-HNS BPPV CPG 2017)

Pregnancy: prefer repositioning maneuvers (definitive, drug-free) and minimise vestibular suppressants/antiemetics — antiemetic safety gating (AAO-HNS BPPV CPG 2017 — limit suppressants; safety)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningcentral_vertigo_stroke_red_flag_route_out
    Any of the 4 D's (diplopia, dysarthria, dysphagia, dysmetria), severe truncal/gait ataxia (cannot stand/walk unaided), other focal neuro sign, or new severe headache/posterior neck pain with vertigo (Kattah Stroke 2009; AAO-HNS BPPV CPG 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghints_central_pattern_route_out
    In acute vestibular syndrome: NORMAL horizontal head-impulse, OR direction-CHANGING gaze-evoked / pure-vertical / pure-torsional nystagmus, OR skew deviation (any one) — "INFARCT" central HINTS pattern (Kattah Stroke 2009; Newman-Toker AEM 2013)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereatypical_central_positional_nystagmus
    Positional nystagmus that is pure-vertical (esp. persistent downbeat), pure-torsional, direction-fixed, lacks latency, does not fatigue, or is out of proportion to vertigo — suggests central positional vertigo / posterior-fossa lesion, NOT BPPV (Bárány Society 2017; AAO-HNS BPPV CPG 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereauditory_symptoms_with_acute_vertigo
    New unilateral hearing loss / tinnitus / aural fullness accompanying acute vertigo (HINTS-plus positive — any new hearing loss in AVS) (Newman-Toker AEM 2013; Bárány vestibular-disorder criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereabcd2_falsely_reassuring_trap
    AVS patient with ABCD2 <4 being considered "low stroke risk" — ABCD2 is INADEQUATE to exclude posterior-circulation stroke in acute continuous vertigo (Newman-Toker AEM 2013)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefall_risk_elderly_bppv
    Older / frail patient (CFS ≥5) with BPPV plus impaired gait-balance, CNS comorbidity, anticoagulation, osteoporosis, or no home support — high fall-injury risk (AAO-HNS BPPV CPG 2017 management-modifier; Rockwood CMAJ 2005)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateintractable_vomiting_dehydration
    Severe persistent vomiting / inability to tolerate oral intake / clinical dehydration with acute vertigo (AAO-HNS BPPV CPG 2017; clinical)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildrecurrent_or_refractory_bppv
    ≥2 prior BPPV episodes, or persistent positive positional test despite ≥2 correctly performed canalith repositioning maneuvers (Hilton Cochrane 2014 — ~36% recurrence; AAO-HNS BPPV CPG 2017)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

BPPV — canalith repositioning (definitive, non-pharm) + strictly short-term symptomatic suppressant
axis: bppv_repositioning_definitive_and_shortterm_symptomaticstep 1 - Step 1 — Definitive treatment: canalith repositioning maneuver (NOT a drug)
Selected step "Step 1 — Definitive treatment: canalith repositioning maneuver (NOT a drug)" — Confirmed posterior- or horizontal-canal BPPV by Dix-Hallpike / supine-roll, no central red flag
  • epley_canalith_repositioning_posterior_canal
    first line
    repositioning_maneuver
    triggers: posterior_canal_bppv, positive_dix_hallpike
    AAO-HNS BPPV CPG 2017 strong recommendation — treat posterior-canal BPPV with a canalith repositioning procedure (Epley). Hilton Cochrane 2014 (PMID 25485940): vertigo resolution OR 4.42 (95% CI 2.62-7.44; 21%→56%), Dix-Hallpike conversion OR 9.62 (95% CI 6.0-15.42). NO post-procedure postural restriction (AAO-HNS strong rec against).
  • semont_liberatory_maneuver_posterior_canal
    second line
    repositioning_maneuver
    triggers: posterior_canal_bppv, cervical_spine_limitation, epley_not_tolerated
    Hilton Cochrane 2014 — Semont equivalent to Epley for posterior-canal BPPV; side-lying technique preferred when neck extension/rotation is limited (cervical spondylosis, vascular)
  • bbq_roll_or_gufoni_maneuver_horizontal_canal
    first line
    repositioning_maneuver
    triggers: horizontal_canal_bppv, positive_supine_roll
    AAO-HNS BPPV CPG 2017 / Bárány 2017 — horizontal-canal BPPV treated with BBQ-roll (Lempert) or Gufoni; canalolithiasis (geotropic) vs cupulolithiasis (apogeotropic) determines direction
  • observation_with_followup_option
    comorbidity specific
    watchful_waiting
    triggers: maneuver_declined, maneuver_not_feasible
    AAO-HNS BPPV CPG 2017 option — observation with follow-up is acceptable initial management (BPPV may remit spontaneously over weeks) when repositioning is declined/not feasible; reassess at ~1 month

outpatient playbook — drug actions (1)

  1. 1. short-term meclizine ONLY if severe nausea precludes maneuver
    rxcui 6676
    25 mg • PO • PRN ≤24-48 h then stop
    trigger: Severe nausea/vomiting blocking positional testing/maneuver (AAO-HNS — against routine use; brief bridge only)
    Suppressant is a bridge, not BPPV therapy; stop once maneuver done

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Recurrent brief (<1 min) vertigo spells triggered by rolling over in bed / lying down / looking up — classic positional BPPV history (Bárány Society criteria, von Brevern 2017; AAO-HNS BPPV CPG 2017); Acute continuous spontaneous vertigo with nystagmus + nausea + head-motion intolerance + gait unsteadiness lasting hours-days (acute vestibular syndrome — apply HINTS, NOT positional testing first) (Kattah Stroke 2009; Newman-Toker Neurol Clin 2015 TiTrATE); Positional or continuous vertigo PLUS any of the 4 D's (diplopia, dysarthria, dysphagia, dysmetria), severe gait/truncal ataxia, or other focal neuro signs — central-vertigo / posterior-circulation-stroke entry (Kattah Stroke 2009; AAO-HNS BPPV CPG 2017).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Benign paroxysmal positional vertigo (with acute-vertigo triage)** (ent.bppv.core.v1).
Phenotype framing: Terminal vestibular differential with named pivots: BPPV (triggered, <1 min, fatiguing canal-specific nystagmus, normal between spells) vs vestibular neuritis (continuous AVS, unidirectional nystagmus, ABNORMAL head-impulse, NO central signs — route to ent.vestibular-neuritis.core.v1) vs posterior-circulation stroke (AVS with NORMAL head-impulse OR direction-changing nystagmus OR skew OR 4 D's — route to neuro.posterior-circulation-stroke.core.v1) vs Ménière (recurrent spontaneous spells minutes-hours + fluctuating low-frequency SNHL/tinnitus/fullness — route to ent.meniere-disease.core.v1) vs vestibular migraine (episodic spontaneous + migraine features, often comorbid with BPPV — route to neuro.vestibular-migraine.core.v1). The BPPV-vs-central pivot = HINTS / triggered-episodic vs continuous-spontaneous.
Scope: Frame the encounter as a TWO-CHANNEL problem: positively diagnose + definitively repositioning-treat BPPV (the commonest peripheral vertigo) AND robustly exclude the dangerous central look-alikes. The explicit peripheral-vs-central decision is the spine of this engine. Definitive stroke/neuritis/Ménière/migraine/falls management is routed OUT by engine_id, not re-authored.

No severity triggers fired against current inputs.

Plan

Regimen axis: **BPPV — canalith repositioning (definitive, non-pharm) + strictly short-term symptomatic suppressant** — step "Step 1 — Definitive treatment: canalith repositioning maneuver (NOT a drug)".
1. epley_canalith_repositioning_posterior_canal (repositioning_maneuver, first line) — AAO-HNS BPPV CPG 2017 strong recommendation — treat posterior-canal BPPV with a canalith repositioning procedure (Epley). Hilton Cochrane 2014 (PMID 25485940): vertigo resolution OR 4.42 (95% CI 2.62-7.44; 21%→56%), Dix-Hallpike conversion OR 9.62 (95% CI 6.0-15.42). NO post-procedure postural restriction (AAO-HNS strong rec against).
2. semont_liberatory_maneuver_posterior_canal (repositioning_maneuver, second line) — Hilton Cochrane 2014 — Semont equivalent to Epley for posterior-canal BPPV; side-lying technique preferred when neck extension/rotation is limited (cervical spondylosis, vascular)
3. bbq_roll_or_gufoni_maneuver_horizontal_canal (repositioning_maneuver, first line) — AAO-HNS BPPV CPG 2017 / Bárány 2017 — horizontal-canal BPPV treated with BBQ-roll (Lempert) or Gufoni; canalolithiasis (geotropic) vs cupulolithiasis (apogeotropic) determines direction
4. observation_with_followup_option (watchful_waiting, comorbidity specific) — AAO-HNS BPPV CPG 2017 option — observation with follow-up is acceptable initial management (BPPV may remit spontaneously over weeks) when repositioning is declined/not feasible; reassess at ~1 month

Setting playbook (outpatient) — Positively diagnose BPPV by positional testing, deliver a definitive repositioning maneuver in the same visit, withhold routine suppressants, exclude central features, and book a 1-month reassessment (AAO-HNS BPPV CPG 2017; Bárány 2017; Hilton Cochrane 2014)
5. short-term meclizine ONLY if severe nausea precludes maneuver 25 mg PO PRN ≤24-48 h then stop — Severe nausea/vomiting blocking positional testing/maneuver (AAO-HNS — against routine use; brief bridge only) (Suppressant is a bridge, not BPPV therapy; stop once maneuver done)

Non-pharmacologic actions:
- Epley (or Semont) for posterior-canal BPPV; BBQ-roll/Gufoni for horizontal-canal — DEFINITIVE treatment (AAO-HNS BPPV CPG 2017)
- Immediate post-maneuver re-test; repeat maneuver if still positive (Hilton Cochrane 2014)
- NO post-procedure postural restrictions (AAO-HNS strong recommendation against)
- NO routine imaging / vestibular testing when BPPV criteria met (AAO-HNS strong recommendation against)
- Educate: recurrence ~36%, self-Epley for recurrence, vestibular safety/fall counselling (Hilton Cochrane 2014; AAO-HNS)

AVOID / contraindication checks:
- Avoid routine and chronic vestibular suppressants in bppv (AAO HNS BPPV CPG 2017 — recommendation AGAINST antihistamine/benzodiazepine routine use; repositioning is definitive)
- Benzodiazepine and antihistamine fall and sedation risk elderly (AAO HNS — vestibular suppressants impair compensation + increase falls; minimise in geriatric/frail)
- Prochlorperazine extrapyramidal akathisia counsel (avoid repeated dosing; caution Parkinsonism/elderly)
- Modify maneuver for cervical spine or vascular limitation (Hilton Cochrane 2014 — use side lying Semont / modified technique; avoid forced neck extension rotation)
- Pregnancy prefer repositioning minimise suppressant antiemetic (AAO HNS limit suppressant principle; antiemetic safety gating)
- Do not repositioning treat undiagnosed central positional vertigo (atypical/persistent nystagmus → image + route to neuro.posterior circulation stroke.core.v1, NOT repeated Epley)

Monitoring

Regimen monitoring:
- immediate post maneuver repeat positional test same visit (AAO-HNS BPPV CPG 2017)
- counsel transient residual unsteadiness is not failure (Hilton Cochrane 2014)
- reassess within 1 month for resolution vs persistence (AAO-HNS BPPV CPG 2017 recommendation)
- STOP short term suppressant once repositioning successful (AAO-HNS — no maintenance suppressant)
- re triage any new neuro or auditory feature as central (Saber Tehrani Neurology 2014 — small posterior-fossa strokes missed on early MRI-DWI)

Setting (outpatient) monitoring:
- Same-visit post-maneuver positional re-test (AAO-HNS BPPV CPG 2017)
- ~1-month reassessment for resolution vs persistence (AAO-HNS recommendation)
- Return precautions: new diplopia/dysarthria/dysphagia/dysmetria, severe headache, unsteady gait, hearing loss → urgent re-eval (Kattah Stroke 2009)

Follow-up plan: AAO-HNS recommendation: reassess within ~1 month to document resolution vs persistence. Persistent/recurrent BPPV → evaluate (or refer) for unresolved BPPV vs underlying peripheral/central disorder; pursue secondary-BPPV substrate (head trauma, post-vestibular-neuritis, osteoporosis / low vitamin D — supplementation reduces recurrence). Educate on recurrence (~36% over time — Hilton Cochrane 2014), safety/fall impact, and self-administered home maneuvers (self-Epley) for recurrence. Elderly recurrent BPPV with falls → route to geriatrics.falls.core.v1 for the multifactorial programme.
- Close-out criterion: 1-month reassessment booked; recurrence/secondary-substrate plan + education documented; falls/ENT referral made if criteria met

Monitoring phase: Immediate post-maneuver re-test (repeat Dix-Hallpike/supine roll same visit) to confirm resolution; if persistent, repeat the maneuver (often 2-3 cycles). Counsel transient residual unsteadiness/light-headedness is common for days and is NOT treatment failure. Re-evaluate any new neuro/auditory feature emerging post-treatment as a central red flag (small posterior-fossa strokes can be missed on early MRI-DWI — Saber Tehrani Neurology 2014).

Disposition

Current setting: outpatient — Positively diagnose BPPV by positional testing, deliver a definitive repositioning maneuver in the same visit, withhold routine suppressants, exclude central features, and book a 1-month reassessment (AAO-HNS BPPV CPG 2017; Bárány 2017; Hilton Cochrane 2014)

Disposition criteria:
- Repositioning successful + no red flag + safe gait → discharge with education + 1-month review (AAO-HNS BPPV CPG 2017)
- Persistent/recurrent → ENT referral + evaluate underlying peripheral/central disorder (AAO-HNS recommendation)

Escalation triggers (move to higher acuity):
- Central HINTS pattern / 4 D's / atypical positional nystagmus → ED + route to neuro.posterior-circulation-stroke.core.v1 (Kattah Stroke 2009)
- Refractory after ≥2 repositioning sessions → ENT/neurotology referral (AAO-HNS BPPV CPG 2017)
- Recurrent BPPV + falls in elderly → route to geriatrics.falls.core.v1 (AAO-HNS fall-risk modifier)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Any of the 4 D's (diplopia, dysarthria, dysphagia, dysmetria), severe truncal/gait ataxia (cannot stand/walk unaided), other focal neuro sign, or new severe headache/posterior neck pain with vertigo (Kattah Stroke 2009; AAO-HNS BPPV CPG 2017)
- [LIFE_THREATENING] In acute vestibular syndrome: NORMAL horizontal head-impulse, OR direction-CHANGING gaze-evoked / pure-vertical / pure-torsional nystagmus, OR skew deviation (any one) — "INFARCT" central HINTS pattern (Kattah Stroke 2009; Newman-Toker AEM 2013)
- [SEVERE] Positional nystagmus that is pure-vertical (esp. persistent downbeat), pure-torsional, direction-fixed, lacks latency, does not fatigue, or is out of proportion to vertigo — suggests central positional vertigo / posterior-fossa lesion, NOT BPPV (Bárány Society 2017; AAO-HNS BPPV CPG 2017)

Citations

- AAO-HNS Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update) — Bhattacharyya et al, Otolaryngol Head Neck Surg 2017 (PMID 28248609) + Bárány Society BPPV diagnostic criteria — von Brevern et al 2015/2017 (PMID 29056234) + HINTS (Kattah Stroke 2009 PMID 19762709; Newman-Toker Acad Emerg Med 2013 PMID 24127701) + TiTrATE (Newman-Toker & Edlow Neurol Clin 2015 PMID 26231273) + Cochrane Epley (Hilton & Pinder 2014 PMID 25485940). Reconciled 2026-05-17 — WebSearch confirms the 2017 AAO-HNS update remains current (no 2018-2026 replacement). [PMID:28248609](https://pubmed.ncbi.nlm.nih.gov/28248609/)
- Cited evidence (PMID 28248602) [PMID:28248602](https://pubmed.ncbi.nlm.nih.gov/28248602/)
- Cited evidence (PMID 29056234) [PMID:29056234](https://pubmed.ncbi.nlm.nih.gov/29056234/)
- Cited evidence (PMID 19762709) [PMID:19762709](https://pubmed.ncbi.nlm.nih.gov/19762709/)
- Cited evidence (PMID 24127701) [PMID:24127701](https://pubmed.ncbi.nlm.nih.gov/24127701/)

Last reconciled with current guidelines: 2026-05-17.
References
  • AAO-HNS Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update) — Bhattacharyya et al, Otolaryngol Head Neck Surg 2017 (PMID 28248609) + Bárány Society BPPV diagnostic criteria — von Brevern et al 2015/2017 (PMID 29056234) + HINTS (Kattah Stroke 2009 PMID 19762709; Newman-Toker Acad Emerg Med 2013 PMID 24127701) + TiTrATE (Newman-Toker & Edlow Neurol Clin 2015 PMID 26231273) + Cochrane Epley (Hilton & Pinder 2014 PMID 25485940). Reconciled 2026-05-17 — WebSearch confirms the 2017 AAO-HNS update remains current (no 2018-2026 replacement). — PMID:28248609
  • Cited evidence (PMID 28248602) — PMID:28248602
  • Cited evidence (PMID 29056234) — PMID:29056234
  • Cited evidence (PMID 19762709) — PMID:19762709
  • Cited evidence (PMID 24127701) — PMID:24127701