Dizziness 😵💫
On-call guide to dizziness and vertigo: timing and triggers, posterior circulation red flags, HINTS and Dix-Hallpike when trained, and short-course vestibular suppressants. Based on Irish eMed practice.
📞 When called
- Onset and duration: sudden or gradual; seconds, minutes, hours, or continuous?
- Triggers: head turning/rolling in bed, standing, exertion, or spontaneous?
- Associated: hearing loss, tinnitus, headache, diplopia, dysarthria, dysphagia, weakness, ataxia, chest pain, palpitations, fever?
- Can they walk? Any fall or head injury?
- New meds (antihypertensives, aminoglycosides, aspirin, sedatives)?
- Vitals and capillary glucose. Ask nursing to repeat if not recent.
🚨 Red flags / escalation
- Sudden vertigo or imbalance plus any posterior circulation feature: headache, gait/limb ataxia, diplopia or field loss, dysarthria, dysphagia, or limb weakness (per eMed).
- Senior review if ≥2 new posterior circulation symptoms (especially with stroke risk factors) or any new focal posterior signs (per eMed).
- Acute ataxia + vertigo ± headache ± vomiting without paralysis: consider cerebellar haemorrhage. Urgent CT and neurosurgical opinion.
- Presyncope, chest pain, palpitations, or abnormal ECG: syncope/cardiac pathway, not vestibular treatment alone.
- Fever or sepsis features: local sepsis pathway.
- New unilateral sensorineural hearing loss: ENT follow-up (exclude tumour). Confirm with Rinne/Weber after bedside hearing check.
🧾 History & examination
- Onset, duration, repetition, hearing/tinnitus, headache, vomiting, diplopia, recent meds. Separate true vertigo (illusion of motion) from orthostatic light-headedness and imbalance.
- Vitals. Postural BP if symptoms on standing (see Lying-standing BP).
- ECG if presyncope, syncope, chest pain, or arrhythmia concern.
- Neuro: cranial nerves, limbs, cerebellum, speech, fields, gait. Document if they can walk unsupported.
- Ears: vesicles (Ramsay Hunt), otitis, hearing (finger rub; Rinne/Weber if deficit).
- Dix-Hallpike: only for brief (<30 s) positional episodes with no spontaneous nystagmus. Peripheral BPPV: 2–20 s latency, fatigable, unidirectional, <1 min. Immediate, non-fatiguing, multidirectional, or >1 min: worry central.
- HINTS: only if trained and ongoing vertigo with spontaneous nystagmus. Not for episodic positional or resolved symptoms. If not trained, escalate sudden AVS via local stroke pathway (NICE NG127).
💡 HINTS (trained only)
- Reassuring (peripheral): unidirectional nystagmus + no skew + abnormal h-HIT in one direction only.
- Dangerous (central): normal h-HIT, or direction-changing nystagmus, or any skew.
- In ongoing vertigo with nystagmus: abnormal h-HIT supports vestibular neuritis; normal h-HIT suggests stroke.
How to perform HINTS
- Only if trained, and only with ongoing vertigo and spontaneous nystagmus at the time of testing. Do not use for episodic positional dizziness or resolved symptoms.
🔬 Investigations
- Bedside: glucose; ECG if cardiac/presyncope; lying/standing BP if postural.
- Bloods as indicated: FBC, U&E (± broader if sepsis, anaemia, metabolic).
- No routine imaging for classic BPPV or clear peripheral features.
- CT is insensitive for early posterior ischaemia. Use local stroke pathway (CT/MRI ± stroke team) if central features or dangerous HINTS.
- Urgent CT + neurosurgery if cerebellar haemorrhage suspected.
🔍 Don’t forget (differentials)
- BPPV: brief spinning with head position change; positive Dix-Hallpike.
- Vestibular neuritis: continuous vertigo, nausea, unidirectional nystagmus; hearing usually spared.
- Labyrinthitis: as above plus hearing loss.
- Ménière's: episodic vertigo, tinnitus, progressive hearing loss.
- Vestibular migraine: episodic vertigo ± migraine features (still exclude stroke if new posterior signs).
- Posterior stroke/TIA: sudden vertigo or imbalance with brainstem/cerebellar signs.
- Cerebellar haemorrhage: acute ataxia, vertigo, headache, vomiting.
- Orthostatic hypotension: on standing; often drug-related.
- Arrhythmia/presyncope: prodrome, palpitations, abnormal ECG.
- Drugs: aminoglycosides, aspirin, sedatives, antihypertensives.
- Ramsay Hunt: ear vesicles, facial palsy ± vertigo/hearing loss.
- Anaemia, hypoglycaemia, dehydration.
📊 Central vs peripheral
Symptoms
- Peripheral
- Intense spinning; position-aggravated; hearing/tinnitus possible
- Central
- Often less intense; not clearly positional; hearing rarely affected
Nystagmus
- Peripheral
- Unidirectional horizontal; reduces with fixation; BPPV burst on Dix-Hallpike <30 s
- Central
- Vertical, direction-changing, or persistent downbeat on positional testing
Other signs
- Peripheral
- Usually isolated vestibular
- Central
- Brainstem/cerebellar signs
Examples
- Peripheral
- BPPV, vestibular neuritis
- Central
- Stroke, MS, Chiari, cerebellar degeneration, some meds
| Peripheral | Central | |
|---|---|---|
| Symptoms | Intense spinning; position-aggravated; hearing/tinnitus possible | Often less intense; not clearly positional; hearing rarely affected |
| Nystagmus | Unidirectional horizontal; reduces with fixation; BPPV burst on Dix-Hallpike <30 s | Vertical, direction-changing, or persistent downbeat on positional testing |
| Other signs | Usually isolated vestibular | Brainstem/cerebellar signs |
| Examples | BPPV, vestibular neuritis | Stroke, MS, Chiari, cerebellar degeneration, some meds |
💊 Management
- BPPV: Epley if trained and no unstable C-spine; otherwise refer (NICE NG127).
- Peripheral AVS (neuritis/labyrinthitis): brief suppressant (e.g. prochlorperazine 5 mg TDS or cyclizine PO TDS per formulary), then early mobilisation. Avoid prolonged suppressants (per eMed).
- Review/stop triggering drugs when appropriate.
- Central: stroke pathway if CVA suspected; urgent imaging + neurosurgery if cerebellar bleed; neurology if MS suspected.
- Orthostatic: fluids, review culprits, gradual mobilisation, falls precautions (see Lying-standing BP and Falls).
- Presyncope/syncope: ECG and syncope workup (see Syncope).
- Recurrent peripheral attacks or chronic unilateral hearing loss: ENT / vestibular physio per local service.
- Safety-net: escalate if new focal neurology, cannot walk, severe headache, fever, chest pain, or unexplained falls.
Related NICE guidance
NICENICE NG127 — Suspected neurological conditions: recognition and referral (2019)
Full guidance on nice.org.uk. BetterCall is not endorsed by NICE.
Educational reference only. Medical disclaimer