A 36-year-old man presents with dizziness and nausea since awakening four hours ago. When he turns a certain way in bed, he feels as though he is on a carousel, but the symptoms resolve after about a minute. He has had two episodes of nonbloody vomiting; vital signs are normal and neurologic examination is intact. What is the most appropriate next step?

• A. Romberg test
• B. Head impulse test
• C. CT head
• D. Dix-Hallpike Maneuver

Answer: (D)

This presentation fits benign paroxysmal positional vertigo (BPPV): brief episodes of spinning triggered by moving the head, with nausea, a normal neurologic exam, and quick resolution. BPPV happens when tiny crystals (otoconia) become dislodged and float into a semicircular canal, most often the posterior canal. When the head changes position, these crystals move the fluid and falsely signal spinning, producing a short vertigo spell.

The Dix-Hallpike maneuver is the test of choice because it directly reproduces the head positions that provoke BPPV and typically triggers the characteristic vertigo along with a distinctive, direction-changing nystagmus. Performing this maneuver now would confirm the diagnosis and guide treatment. If positive, it is followed by canalith repositioning maneuvers (like the Epley maneuver) to move the crystals out of the canal and relieve symptoms.

Why the other options aren’t as helpful here: Romberg testing mainly assesses static balance and proprioception, not the brief, position-triggered vertigo of BPPV. The head impulse test evaluates the vestibulo-ocular reflex and would be more suggestive of an acute unilateral vestibular loss rather than BPPV. A CT head isn’t indicated in a patient with isolated vertigo and a normal neurologic exam when a benign positional vertigo is suspected.