# Peripheral vertigo (BPPV & vestibular neuronitis) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: NICE CKS Vertigo 2022 · Betahistine 16 mg tablets SmPC sections 4.1-4.4 (eMC product 7053) · Dramamine Original 50 mg tablets, Directions (DailyMed SetID f9302a5a-295a-4501-9332-e3f5eb387362) - Verified date: 2026-08 ## Verified against - Betahistine 16 mg tablets SmPC sections 4.1-4.4 (eMC product 7053) - Dramamine Original 50 mg tablets, Directions (DailyMed SetID f9302a5a-295a-4501-9332-e3f5eb387362) ## Treatment metadata - Dimenhydrinate — 50 mg — oral.solid ## Complete treatment card ```text PERIPHERAL VERTIGO (BPPV & VESTIBULAR NEURONITIS) Sources: NICE CKS Vertigo 2022 · Betahistine 16 mg tablets SmPC sections 4.1-4.4 (eMC product 7053) · Dramamine Original 50 mg tablets, Directions (DailyMed SetID f9302a5a-295a-4501-9332-e3f5eb387362) Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (11) - Most say dizziness; first confirm they mean a false sense of movement or spinning [dizziness] - A detailed timeline of the attacks is the most useful single thing for finding the cause - Recurrent brief spells of a few minutes or less usually mean BPPV - One episode lasting minutes to hours suggests vestibular migraine, or something worse such as a TIA - Attacks running over days occur in both peripheral and central disease - Nausea and vomiting come with any acute attack and point to no particular cause [nausea · vomiting] - Ask about double vision, slurred speech, difficulty swallowing, numbness or weakness, which point centrally [difficulty swallowing · double vision · numbness · slurred speech] - Headache, dislike of light and visual aura go with vestibular migraine [headache · photophobia] - Deafness and tinnitus alongside the spells suggest Meniere disease [hearing loss · tinnitus] - A recent viral illness precedes acute labyrinthitis and vestibular neuritis - Review medicines, alcohol and substance use; anticonvulsants, salicylates and antibiotics affect balance SIGNS - what you find (12) - Assessing nystagmus is the central part of the examination [nystagmus] - With a peripheral lesion the fast phase beats away from the bad ear and grows on gazing that way - Peripheral nystagmus keeps one direction whichever way the eyes look; central nystagmus can reverse [nystagmus] - Peripheral nystagmus is horizontal with a twist, and is never purely vertical or purely torsional [nystagmus] - For the head impulse test, the patient fixes on a distant target and the head is turned quickly about 15 degrees - Eyes dragged off the target with a corrective flick back means a peripheral lesion on that side - Test for skew by covering one eye and watching the other shift; a slight skew suggests a central lesion - A normal head impulse with direction-changing nystagmus or a skew is worrying for a central lesion [nystagmus] - An abnormal head impulse with one-direction nystagmus and no skew strongly indicates a peripheral lesion [nystagmus] - In unilateral peripheral disease the patient leans or falls towards the bad side - With a cerebellar lesion the patient often cannot walk unaided and falls in no fixed direction - Hearing loss in just one ear points strongly towards a peripheral cause [hearing loss] TESTS (12) - The Dix-Hallpike manoeuvre is the diagnostic test of choice for posterior canal BPPV - Turn the head 45 degrees, lie the patient back fast, head hanging some 20 degrees beyond the table edge - Hold 30 seconds, sit up and watch 30 seconds more, then repeat to the other side - It is positive if the manoeuvre brings on vertigo, with or without nystagmus - In the Unterberger test the patient marches on the spot with eyes shut for 60 seconds - It is positive if the body turns to one side while marching - Otoscopy excludes obvious infection such as acute otitis media - Weber and Rinne screen at the bedside for conductive and sensorineural loss - Audiometry and tympanometry beat bedside testing for hearing loss and middle ear fluid - Blood tests usually fail to identify the cause - Image the brain when there are stroke risk factors, focal deficits, a new headache, or an examination that does not fit a peripheral lesion - MRI with MR angiography is preferred; CT resolves the back of the brain poorly, but thin cuts through brainstem and cerebellum will serve if MRI is out of reach IF NOT THIS - what else fits (9) - First separate true vertigo from unsteadiness, near-fainting and lightheadedness - Causes span vascular, infectious, traumatic, inflammatory, demyelinating, metabolic, drug- induced and tumour - Repeated spells of a few minutes or less: BPPV - A single spell of minutes to hours: vestibular migraine, or a TIA - Days of continuous vertigo: vestibular neuritis, or a tumour at the cerebellopontine angle - Deafness and tinnitus with the attacks: Meniere disease - Excluding a central cause matters most, since vertebrobasilar stroke and MS progress or kill - Having no focal neurological symptoms does not exclude a central process; having them demands investigation - A medicine can be the cause: anticonvulsants, salicylates or antibiotics Source StatPearls "Vertigo in Clinical Practice: Evidence-Based Diagnosis and Treatment" - disease-level clinical article Status traced to the source above 1. DIMENHYDRINATE [1st line] Adult 50-100 mg orally every 4-6 hours (max 400 mg/day) - short-term (1-3 days during acute phase) Peds 2 to under 6 years: Half a 50 mg tablet every 6 to 8 hours, and no more than one and a half tablets in 24 hours 6 to under 12 years: Half to one 50 mg tablet every 6 to 8 hours, and no more than 3 tablets in 24 hours (Children 6 to under 12 years: half to one 50 mg tablet every 6-8 hours, not more than 3 tablets in 24 hours. Children 2 to under 6 years: half a tablet every 6-8 hours, not more than one and a half tablets in 24 hours.) Source Dramamine Original 50 mg tablets, Directions (DailyMed SetID f9302a5a-295a-4501-9332-e3f5eb387362) Why Antihistamine with anticholinergic and antiemetic activity that suppresses vestibular nuclei signalling and the associated nausea; first-line short-term drug therapy for acute vestibular neuronitis, while BPPV itself is treated with the Epley manoeuvre rather than medication. Caution First-line for acute vestibular neuronitis (short-term only, max 3-5 days); BPPV requires Epley maneuver, not medication. Sedation and anticholinergic side effects (dry mouth, blurred vision) are common. Use strictly for acute severe vertigo; long-term use impairs compensation. Avoid driving or operating machinery. Egypt DRAMENEX 50MG 20 TABS. KAHIRA 28.00 EGP (1.40/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)