Acute dizziness and vertigo: workup and approach
Classify acute dizziness by timing and triggers (acute vestibular syndrome, spontaneous episodic, triggered episodic), not by the patient's word choice. Use HINTS plus gait in continuous vertigo with nystagmus to separate vestibular neuritis from posterior-circulation stroke, and the Dix–Hallpike for positional vertigo.
Presenting complaint
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- ACEP GRACE-3 (2023): use HINTS only if trained and in acute vestibular syndrome with nystagmus; CT head is not recommended to exclude stroke in these patients; MRI may be falsely negative in the first 48 hours
- AAO-HNS 2017 BPPV guideline: diagnose with Dix–Hallpike, treat with canalith repositioning; do not routinely image or use vestibular suppressants
- Steroids for vestibular neuritis remain of uncertain benefit
Differential diagnoses
- Posterior-circulation stroke or TIA (can't miss)
- Vertebral artery dissection (can't miss)
- BPPV
- Vestibular neuritis or labyrinthitis
- Vestibular migraine, Ménière disease
- Non-vestibular: orthostatic hypotension, arrhythmia, hypoglycemia, medication effect, anemia
02Assess
Risk scores and decision tools
- HINTS (head impulse, nystagmus, test of skew); HINTS-plus adds new hearing loss
- Dix–Hallpike maneuver (posterior canal) and supine roll test (horizontal canal)
- ABCD² does not reliably risk-stratify dizziness
Key history questions
- Timing: continuous for days vs episodic; seconds vs minutes vs hours
- Triggers: head position change vs spontaneous
- Neurological symptoms: diplopia, dysarthria, dysphagia, numbness, weakness, ataxia
- Neck pain or trauma (dissection), headache
- Hearing loss, tinnitus, ear fullness; migraine history; vascular risk factors
Examination findings
- Nystagmus: direction, gaze-evoked, vertical (central signs)
- Head impulse test (abnormal = peripheral), skew deviation (central)
- Gait and truncal ataxia (inability to walk unaided suggests central)
- Cranial nerves, cerebellar testing, orthostatic vitals
03Investigate
Initial investigations
- Glucose, ECG
- Orthostatic vital signs
- CBC and BMP if non-vestibular cause suspected
Advanced investigations
- MRI brain with DWI if central features or HINTS concerning (repeat if early MRI negative and suspicion persists)
- CTA or MRA head and neck for suspected dissection or basilar disease
- Audiometry for hearing loss
04Treat
Immediate management
- Suspected stroke: stroke code; consider thrombolysis or thrombectomy per stroke pathway
First-line treatment
- Posterior canal BPPV: Epley maneuver; horizontal canal: Lempert (barbecue roll) or Gufoni
- Vestibular neuritis: short course of symptomatic antiemetic or vestibular suppressant (≤3 days), early vestibular rehabilitation
- Antiemetics: ondansetron, meclizine, or prochlorperazine
Second-line treatment
- Persistent symptoms: vestibular physical therapy
- Ménière disease or vestibular migraine: ENT or neurology for specific therapy
Specialist referrals
- Neurology for central features
- ENT for hearing loss or recurrent episodes
- Vestibular physical therapy
05Disposition
Admission criteria
- Central signs or abnormal HINTS
- Unable to walk
- Persistent vomiting or dehydration
Safe discharge criteria
- Clear peripheral diagnosis (positive Dix–Hallpike with response, or reassuring HINTS from a trained examiner)
- Able to walk and keep fluids down
Follow-up timing
- Primary care or ENT in 1–2 weeks; reassess BPPV after repositioning
Patient instructions
- Return for new weakness, double vision, slurred speech, worst headache, or inability to walk
Monitoring
- Serial neuro exams while in ED
Clinical pearls and pitfalls
- A normal head impulse test in continuous vertigo is a red flag for stroke
- Early MRI misses up to 10–20% of posterior circulation strokes
- Avoid prolonged meclizine; it slows vestibular compensation
RefGuidelines and landmark evidence
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.