chronic

Peripheral vertigo (BPPV & vestibular neuronitis)

Treatment options, dosing, cautions and Egyptian brands from the shipped Dawaa Reference card.

Evidence status

Checked against the sources named below

Sources3 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 against2 documents

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 date2026-08

Presentation reference

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

SourceStatPearls "Vertigo in Clinical Practice: Evidence-Based Diagnosis and Treatment" - disease-level clinical article

Presentation findings are traced to the source above.

DIMENHYDRINATE

1st line

Strength50 mg

Formoral.solid

Adult dose and duration

50-100 mg orally every 4-6 hours (max 400 mg/day) - short-term (1-3 days during acute phase)

Paediatric dose

(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.)

Dose by age
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

Dose 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.

Cautions

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.

Egyptian brands

Egyptian brand	Manufacturer	Indicative price
DRAMENEX 50MG 20 TABS.	KAHIRA	28.00 EGP (1.40/unit)

Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy.