Running the clinic
Treatment & rehabilitation
Eight conditions account for almost all the work. The clinic's job is to deliver each one well — pathways defined, outcome metrics tracked, escalation criteria written down.
The case-mix of a typical vertigo clinic is dominated by BPPV, vestibular migraine, vestibular neuritis, PPPD, Ménière's and the multisensory imbalance of the older patient. Two more — SCDS and the surgical end of refractory BPPV — round out the service.
Most of these have evidence-based treatment pathways. A vertigo clinic's value is less about novel science and more about applying the established pathways consistently, the same way, every time.
The Epley manoeuvre has strong Cochrane-grade evidence for PC-BPPV.1,2 Methylprednisolone shortens caloric recovery in vestibular neuritis but produces only modest patient-reported gains;3 early vestibular rehabilitation is the stronger intervention.7,8
Vestibular migraine — the commonest cause of recurrent episodic vertigo in under-50s — is treated as migraine, not as vestibular disease;4 propranolol, topiramate and amitriptyline are the typical first-line prophylactics. PPPD needs three pillars in combination — education, vestibular rehab and an SSRI.5,6
Surgical capacity belongs in the referral network, not the clinic itself for most services. Posterior-canal occlusion for intractable BPPV10 and round- window reinforcement for disabling superior canal dehiscence9 are tertiary procedures that should sit behind a formal multidisciplinary review.
For every condition, define the outcome metric and the escalation criteria before the first patient walks in. The cards below summarise each pathway and the metric to track.
Treatment pathways
- Same-visit diagnosis on Dix-Hallpike
- On-site repositioning chair or couch
- Patient instructions for residual dizziness
The single highest-impact intervention the clinic can offer: 5 minutes of work resolves the most common cause of episodic vertigo. Repeat at one week if the Dix-Hallpike is still positive.
- Supine roll with goggles
- Geotropic vs apogeotropic interpretation pathway
- Forced prolonged-position option for cupulolithiasis
Identifying geotropic versus apogeotropic patterns is the critical step — they need different manoeuvres. Lateralisation uses the 'stronger ear' for geotropic, 'weaker ear' for apogeotropic.
- HINTS at presentation, vHIT within 7 days
- Vestibular physio referral within 72 hours
- Antiemetic + steroid taper if early-presenting
Methylprednisolone shortens caloric recovery but the effect on patient-reported outcome is modest. Vestibular rehab is the strongest evidence-based intervention.
- Audiometric monitoring (3-monthly)
- Intratympanic injection capability
- Diet and lifestyle counselling
Escalate stepwise: diet → diuretic → intratympanic steroid → gentamicin or surgery. Hearing trajectory is the safety floor for ablative options.
- Headache history at first visit
- Trigger diary
- Co-management pathway with neurology
The commonest cause of recurrent episodic vertigo in the under-50s. Diagnosis is by Bárány criteria; treatment mirrors migraine, not vestibular suppression.
- PPPD-aware rehab (visual desensitisation)
- Clinical psychology / CBT referral
- Slow SSRI titration with side-effect monitoring
Three pillars work in combination — none alone. Set expectations: recovery is in months, not weeks. Address visual dependence early.
- VEMP threshold testing
- Temporal-bone CT review
- Surgical referral pathway
Diagnosis rests on CT + low-threshold cVEMP; treatment is surgical only when symptoms are disabling. Reassurance and avoidance are first-line for the rest.
- Geriatrician / falls-clinic link
- Home-environment assessment
- Group balance exercise programme
Rarely a single-pathology problem. The biggest win is often deprescribing — sedating antihistamines and benzodiazepines worsen postural control.