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.
- HINTS is not a general dizziness screen. Use it only in a currently symptomatic acute vestibular syndrome with spontaneous nystagmus, and only when the examiner has specific training and can act on the result.
- A central HINTS pattern includes normal head impulse, direction-changing gaze-evoked nystagmus or skew; HINTS-plus adds new unilateral hearing loss because anterior inferior cerebellar artery stroke can affect the labyrinth.
- Severe truncal ataxia, inability to sit unaided, vertical nystagmus, focal cranial or limb signs, new headache or neck pain and high vascular risk lower the threshold for stroke imaging and specialist review.
- Posterior-canal BPPV produces brief episodes triggered by position change with a characteristic delayed, transient upbeat torsional nystagmus on Dix–Hallpike; the Epley manoeuvre treats the affected canal when safe.
- A negative or atypical Dix–Hallpike does not exclude horizontal-canal BPPV; persistent downbeat, non-fatiguing or non-canal nystagmus raises central positional disease.
- Vestibular neuritis causes prolonged peripheral vestibular symptoms without new hearing loss or focal neurology; hearing loss shifts the differential toward labyrinthitis, Ménière disease or an AICA vascular syndrome.
- Ménière disease produces recurrent spontaneous vertigo with fluctuating unilateral hearing, tinnitus or aural pressure; diagnosis requires audiovestibular assessment and exclusion of mimics.
- Vestibular migraine can occur with or without simultaneous headache, but a first severe episode or focal signs still requires vascular and structural assessment rather than diagnosis by migraine history alone.
- Vestibular suppressants and antiemetics are short-term aids in severe acute peripheral disease; prolonged use can delay central compensation. Early safe mobilisation and vestibular rehabilitation support recovery after dangerous causes are excluded.
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.
Acute continuous vertigo over days with nausea, unidirectional horizontal-torsional nystagmus and impaired head impulse, but no new hearing loss or focal neurology, supports unilateral peripheral vestibular failure after stroke assessment.
Immediate persistent downbeat, pure vertical or direction-incongruent nystagmus, minimal fatigability, prominent gait ataxia or other focal signs during positional testing points away from typical canal BPPV.
Light-headedness, visual dimming and weakness after standing with orthostatic pressure fall, bleeding, arrhythmia or vasovagal prodrome suggests global perfusion disturbance rather than a primary vestibular lesion.
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.
- After stroke is reasonably excluded, use only short symptomatic medication if needed, encourage safe mobilisation and arrange vestibular rehabilitation and review of persistent or changing signs.