Persistent positional vertigo after manoeuvre

D. Reassess the diagnosis and repeat an appropriate repositioning manoeuvre

Persistent symptoms should prompt reassessment for unresolved BPPV, the involved canal and alternative vestibular or neurological causes. Repeating a correctly selected canalith-repositioning manoeuvre is reasonable when findings remain typical.

Why every option is right or wrong

A. Commence long-term prochlorperazine: Chronic vestibular suppressants do not reposition otoconia and may impede compensation.

B. Order routine CT brain: Typical BPPV does not require routine imaging; imaging is reserved for atypical or focal features.

C. Advise permanent avoidance of head movement: Activity restriction does not treat the disorder and can reinforce imbalance and fear.

D. Reassess the diagnosis and repeat an appropriate repositioning manoeuvre: Persistent symptoms should prompt reassessment for unresolved BPPV, the involved canal and alternative vestibular or neurological causes. Repeating a correctly selected canalith-repositioning manoeuvre is reasonable when findings remain typical.

E. Refer directly for vestibular nerve section: Ablative surgery is grossly disproportionate to common, usually treatable BPPV.

What if the scenario changed?

If positional nystagmus were persistent, down-beating or accompanied by ataxia, investigate a central positional syndrome rather than simply repeating Epley manoeuvres.