Synopsis
Use timing, triggers, eye movements, hearing and neurological findings to distinguish common peripheral vestibular syndromes from posterior-circulation and other central causes without misapplying bedside tests.
- Ask what the patient means by dizziness, then classify timing and triggers: a single continuous acute vestibular syndrome, recurrent spontaneous attacks, brief triggered episodes or chronic disequilibrium generate different differentials.
- Movement can worsen almost any vertigo; a true trigger initiates an otherwise absent brief episode. Do not diagnose benign positional vertigo merely because a continuously dizzy patient feels worse turning the head.
- Acute vestibular syndrome comprises continuous vertigo or dizziness lasting days, spontaneous nystagmus, nausea or vomiting, head-motion intolerance and gait instability. Important causes include vestibular neuritis and posterior-circulation stroke.
Key red flags
Abrupt continuous vertigo with severe truncal ataxia, focal cranial or limb signs, central nystagmus, skew, new hearing loss or headache or neck pain supports urgent brainstem-cerebellar vascular assessment.
Investigation priorities
Identify central signs and establish whether the patient can sit, stand and walk safely.
Management branches
Vertigo or dizziness is continuous for hours to days with spontaneous nystagmus, vomiting, motion intolerance or gait unsteadiness.
- Perform ABCDE and glucose, establish last known well, headache and neck pain, vascular risk and hearing change and examine eye movements, skew, cranial nerves, limbs, sensation, coordination and sitting or walking ability.
- If trained and the syndrome is appropriate, perform HINTS-plus; any central feature, severe truncal ataxia, new hearing loss or unreliable examination prompts immediate stroke-team and vascular-imaging assessment.
Key medicines
Canalith-repositioning manoeuvre for posterior-canal BPPVA trained clinician performs one Epley sequence for the affected posterior canal and repeats or reviews according to symptom and nystagmus response, local competence and patient tolerance.