Dizziness 😵‍💫

• 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.

• 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.

• 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).

• 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.

• 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.

• 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.

• 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.

• 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.

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