← All presentations

Dizziness & Vertigo

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

LearnQuick referenceClinical practice

Your objective: explain the approach, recognize important warning signs, then test your recall.

Abbreviations explained
ACS
Acute coronary syndrome
OMI
Occlusion myocardial infarction
ECG
Electrocardiogram
PE
Pulmonary embolism
POCUS
Point-of-care ultrasound
QTc
QT interval corrected for heart rate
LBBB
Left bundle branch block
RBBB
Right bundle branch block
hs-cTn
High-sensitivity cardiac troponin
CTA
Computed tomography angiography
ICU
Intensive care unit
Filter

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

  1. Timing and triggers first: continuous acute vestibular syndrome, spontaneous episodes, or triggered episodes.
  2. If positional and seconds-long: Dix-Hallpike / Epley (BPPV).
  3. HINTS only in ongoing acute vestibular syndrome with nystagmus, by a trained examiner. Without nystagmus, assess gait and neurologic findings.
  4. Sustained vertigo with vascular risks: MRI-DWI (CT misses posterior stroke).

Classify dizziness by timing and triggers: continuous acute vestibular syndrome, spontaneous episodes, or triggered episodes; symptom labels alone are unreliable.

Duration, triggers, and HINTS (only in ongoing acute vestibular syndrome with nystagmus, by a trained examiner) outperform early CT; sustained vertigo with vascular risk factors needs posterior-circulation imaging (MRI-DWI).

Posterior circulation stroke Critical

Key: Sustained vertigo + HINTS central signs, or any focal/cranial-nerve deficit — MRI-DWI (CT misses most).

Cerebellar hemorrhage Critical

Key: Headache, ataxia, inability to walk — CT now; neurosurgery.

Vestibular schwannoma / CPA mass Emergent

Key: Progressive unilateral hearing loss + vertigo — MRI.

BPPV Common

Key: Brief (<1 min) positional vertigo, positive Dix-Hallpike — Epley maneuver treats in the ED.

Vestibular neuritis Common

Key: Acute sustained vertigo, HINTS peripheral, no hearing loss — symptomatic care + vestibular rehab. Do not use HINTS for episodic symptoms.

Ménière disease Common

Key: Episodes with tinnitus, fluctuating hearing loss, ear fullness.

Presyncope / arrhythmia / orthostatic Common

Key: Light-headed, not rotational — evaluate like syncope.

Tick what your patient has — the banner updates as you go.

Character

spinning (vertigo) vs light-headed vs imbalance

Duration

seconds (BPPV), hours (Ménière, TIA), days (neuritis, stroke)

Triggers

position changes (BPPV), head motion, standing (orthostatic)

Vascular risks

age, hypertension, diabetes, smoking, atrial fibrillation

Hearing change, tinnitus, diplopia, dysarthria, dysphagia, headache/neck pain

HINTS in ongoing AVS with nystagmus, by a trained examiner: a corrective saccade supports peripheral dysfunction but can occur in stroke; a normal HIT is a central warning in this setting. Interpret the complete examination, including hearing. Direction-changing or vertical nystagmus = central. Test-of-skew (vertical refixation) = central

Gait — unable to walk at all suggests central

Neuro

cranial nerves, cerebellar tests, dysmetria

Dix-Hallpike if positional symptoms; otoscopy

Orthostatic vitals if presyncopal

Bedside

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

Labs

  • As directed by the picture: CBC, glucose, electrolytes

Imaging

  • MRI-DWI for suspected central cause (CT is poor for the posterior fossa)
  • CT first if hemorrhage is suspected; CTA/MRA for vascular assessment
Medication safety reminder

Use this as a first-pass prompt; verify all medications, doses, concentrations, contraindications, weight, pregnancy status, and local protocols before administration.

Check indication, allergy, route, renal/hepatic risk, interactions, monitoring, and local formulary.

Discharge

  • BPPV (post-Epley with home exercises), peripheral neuritis with a confident HINTS-peripheral exam, Ménière flare with follow-up — safety-net advice.

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.

Use objective reassessment and the local pathway.

Before the next decision · reassess and hand over

Use these learning prompts with the presentation’s pathway. They are not discharge criteria.

  1. Reassess: compare symptoms, observations and examination with the initial assessment and response to treatment.
  2. Warning signs for Dizziness & Vertigo:
    • 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
  3. Reconsider: check unresolved findings and alternative explanations, including the pitfalls below.
  4. Escalate: communicate deterioration, uncertainty or needs beyond the current setting.
  5. Plan the transition: identify outstanding results, responsibility for follow-up, patient understanding and specific return advice.
Review this presentation’s disposition pathway →Practice a handover →

Clinical Pearls

  • HINTS requires ongoing AVS with nystagmus and a trained examiner; use gait/neurologic assessment without nystagmus.
  • An abnormal HIT supports peripheral dysfunction but does not exclude stroke; interpret all HINTS findings and hearing together.
  • CT misses most posterior strokes — MRI-DWI when suspicion persists.
  • BPPV is diagnosed with Dix-Hallpike and treated with Epley in the ED.

Pitfalls

  • HINTS is invalid in episodic/positional vertigo — that is a Dix-Hallpike question, not a HINTS question.
  • CT is insensitive for posterior ischemia. Early MRI-DWI can also be falsely negative; persistent central concern needs specialist assessment and sometimes repeat imaging.
  • A “dizzy” elderly patient with falls may have presyncope, not vertigo — re-interview.
  • Nystagmus that changes direction with gaze = central until proven otherwise.
  • Do not treat undifferentiated vertigo with meclizine and discharge — the exam decides.
  • BPPV can coexist with serious causes; re-test if atypical.
PRACTICE REFRESHER

Rapid recall

Test your first action and the dangerous diagnoses before revealing the answer.

01 · First move

Before you scroll, what needs to happen first?

02 · Immediate threats

Name at least two diagnoses that cannot wait.

PRIVATE TO THIS DEVICE

Your learning note

Capture a weak point, a teaching pearl, or a question to take to your next shift.

Review schedule starts when marked reviewed
HeadacheSyncopeDiplopia

Selected guidance · source check 2026-09-07. These 2 source links support selected teaching points, not a complete review of this topic. Check population, setting and local protocol before applying a recommendation.

  • Rosen’s Emergency Medicine, 10th ed. (2023) — dizziness & vertigo
  • HINTS exam: Kattah et al., Stroke 2009; subsequent AVS imaging studies
  • 2026 AHA/ASA stroke guidance; SAEM GRACE-3 (2023) acute dizziness guideline
← HeadacheAltered Mental Status →