Dizziness & Vertigo

The one question: is it the inner ear or the brainstem?

Educational first-pass aid. Reassess the patient, confirm doses and use local protocols.

1 · First minutes

Timing and triggers first: continuous acute vestibular syndrome, spontaneous episodes, or triggered episodes.
If positional and seconds-long: Dix-Hallpike / Epley (BPPV).
HINTS only in ongoing acute vestibular syndrome with nystagmus, by a trained examiner. Without nystagmus, assess gait and neurologic findings.

Any new focal/cranial-nerve deficit or severe imbalance
Sudden headache with vertigo (hemorrhage)
Normal head-impulse test, direction-changing or vertical nystagmus, or skew deviation
Vascular risk factors with sustained (not positional) vertigo
New hearing loss with neuro signs
Inability to stand or walk even with support

Trained HINTS plus hearing assessment for ongoing AVS with nystagmus; assess gait severity when nystagmus is absent
Glucose; orthostatics; ECG if presyncopal

Posterior circulation stroke
Sustained vertigo + HINTS central signs, or any focal/cranial-nerve deficit — MRI-DWI (CT misses most).
Cerebellar hemorrhage
Headache, ataxia, inability to walk — CT now; neurosurgery.

Admit

High-risk acute vestibular syndrome while MRI is arranged, Ménière with intractable vomiting, electrolyte derangements.

Stroke pathway / neurosurgery

Posterior circulation stroke (thrombolysis/thrombectomy if eligible), cerebellar hemorrhage with mass effect.