When should I consider referring a patient with BPPV for further evalu

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Consider referring a patient with benign paroxysmal positional vertigo (BPPV) for further evaluation or treatment in the following situations:

If the expertise to perform a canalith repositioning procedure (such as the Epley manoeuvre) is not available in primary care, refer to a medically qualified balance specialist for treatment ,.
If physical limitations or medical conditions affect the safety or practicality of performing canalith repositioning procedures in primary care (e.g., neck or back problems, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis, or morbid obesity), seek specialist advice or refer ,.
If a canalith repositioning procedure has been performed and repeated (typically twice) in primary care but symptoms persist, refer to exclude alternative diagnoses ,.
For patients presenting with atypical symptoms or signs such as hearing loss, tinnitus, signs of middle ear infection, neurological symptoms, or involvement of horizontal/anterior canals or multiple canals, referral to a specialist is recommended due to diagnostic and treatment complexity ,.
If the patient becomes dehydrated due to vomiting following acute attacks, hospital admission for intravenous fluids may be required ,.

When should I consider referring a patient with BPPV for further evaluation or treatment?