CLINICAL PRINTABLE
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A one-page Dizziness / Vertigo clinical reference is on the way.
1 · Recognition / Alarm Features
- Clarify the symptom first: vertigo (illusion of movement — room spinning or self-spinning), presyncope (lightheadedness, feeling of impending faint), disequilibrium (unsteadiness without head sensation), or nonspecific dizziness. Each has a distinct differential.
- HINTS exam for acute vestibular syndrome (continuous vertigo >24 hours): Head Impulse test, Nystagmus pattern, Test of Skew. HINTS positive for central cause: normal head impulse (no corrective saccade), direction-changing nystagmus, or vertical skew deviation. A central HINTS pattern is more sensitive for posterior fossa stroke than early MRI.
- BPPV features: brief (seconds to minutes), triggered by head position change (rolling over in bed, looking up, bending forward), no hearing loss, no neurologic symptoms. Positive Dix-Hallpike test (upbeat-torsional nystagmus with latency and fatigability).
- Central red flags requiring urgent neuroimaging: new onset headache with vertigo, diplopia, dysphagia, dysarthria, facial numbness, limb ataxia, gait instability, direction-changing nystagmus, vertical nystagmus, or failure to improve with Epley maneuver.
- Vestibular neuritis vs labyrinthitis: vestibular neuritis — acute vertigo, no hearing loss, no tinnitus. Labyrinthitis — acute vertigo WITH hearing loss and tinnitus. Both are typically post-viral. Distinguish from posterior fossa stroke using HINTS.
2 · Differential / Secondary Causes
BPPV (benign paroxysmal positional vertigo)
Most common cause of vertigo. Canalith repositioning (Epley maneuver) is curative in 80–90% of cases. Posterior canal BPPV: positive Dix-Hallpike with upbeat-torsional nystagmus. Horizontal canal BPPV: positive supine roll test with horizontal nystagmus. Refer to vestibular PT for refractory cases.
Vestibular neuritis
Acute, sustained vertigo (days to weeks) without hearing loss. Post-viral. HINTS exam: abnormal head impulse (peripheral pattern), unidirectional nystagmus, no skew. Treat with vestibular suppressants short-term (meclizine, diazepam) and early vestibular rehabilitation. Steroids (methylprednisolone) may accelerate recovery.
Posterior fossa stroke (cerebellar or brainstem)
Acute vertigo that may mimic vestibular neuritis. Central HINTS pattern: normal head impulse, direction-changing nystagmus, or vertical skew. Associated neurologic symptoms (diplopia, dysarthria, dysphagia, ataxia). MRI DWI may be falsely negative in first 24–48 hours. Admit for monitoring if central cause suspected.
Meniere's disease
Episodic vertigo (20 minutes to 12 hours), fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Endolymphatic hydrops. Low-sodium diet, diuretics (hydrochlorothiazide), betahistine. Intratympanic gentamicin or endolymphatic sac surgery for refractory cases.
Orthostatic hypotension
Presyncope (lightheadedness) on standing, not true vertigo. Drop in SBP ≥20 mmHg or DBP ≥10 mmHg within 3 minutes of standing. Review medications (antihypertensives, diuretics, alpha-blockers). See Orthostatic Hypotension Deep Dive.
3 · Treatment Pathway
BPPV — Epley maneuver
Posterior canal BPPV: Epley maneuver (canalith repositioning). Effective in 80–90% of cases. Can be performed in office. Teach patient home Epley for recurrence. Horizontal canal BPPV: Barbecue roll (Lempert maneuver). Vestibular suppressants are not effective for BPPV and may delay recovery.
Vestibular neuritis — acute management
Vestibular suppressants short-term (3–5 days): meclizine 25 mg TID, diazepam 2–5 mg TID, or promethazine. Avoid prolonged use — delays central compensation. Methylprednisolone 100 mg/day tapered over 3 weeks may improve long-term vestibular function. Early vestibular rehabilitation.
Vestibular rehabilitation
Gaze stabilization exercises, habituation exercises, and balance training. Effective for vestibular neuritis, BPPV recurrence, and chronic dizziness. Refer to vestibular physical therapy for persistent symptoms >4 weeks.
Presyncope / orthostatic dizziness
Identify and treat the underlying cause: dehydration, medication effect, autonomic dysfunction, cardiac arrhythmia. Increase fluid and salt intake. Compression stockings. Review and adjust antihypertensives. Midodrine or fludrocortisone for refractory orthostatic hypotension.
4 · Expected Response
- BPPV after Epley maneuver: resolution of positional vertigo in 80–90% after one treatment. Recurrence rate 15–30% per year — repeat Epley as needed.
- Vestibular neuritis: acute vertigo resolves over days to weeks. Residual unsteadiness may persist for months. Vestibular rehabilitation accelerates recovery.
- Meniere's disease: dietary modification and diuretics reduce attack frequency in 60–80% of patients. Hearing loss may be progressive despite treatment.
5 · Escalation
- Central HINTS pattern (normal head impulse, direction-changing nystagmus, vertical skew): admit for MRI and neurology consultation. Do not discharge with a diagnosis of vestibular neuritis.
- Acute vertigo with new neurologic symptoms (diplopia, dysarthria, dysphagia, limb ataxia, facial numbness): posterior fossa stroke until proven otherwise. Urgent MRI/MRA. Neurology consultation.
- Acute unilateral hearing loss with vertigo: labyrinthitis vs inner ear infarction. Urgent audiology and ENT evaluation. Consider MRI.
- Dizziness with syncope, palpitations, or exertional component: cardiac arrhythmia or structural heart disease. ECG, Holter monitor, echocardiogram.
Apply It · Change One Detail
APPLY IT
A 55-year-old woman presents with 2 days of room-spinning vertigo that started suddenly. No hearing loss, no neurologic symptoms. HINTS exam: abnormal head impulse (corrective saccade), unidirectional horizontal nystagmus, no skew deviation. This is a peripheral pattern — consistent with vestibular neuritis. Prescribe meclizine for 3–5 days, start vestibular rehabilitation, and reassure. No MRI needed with a clearly peripheral HINTS pattern.
CHANGE ONE DETAIL
Change one detail — the same patient has a normal head impulse test (no corrective saccade) and direction-changing nystagmus on lateral gaze. This is a central HINTS pattern. Posterior fossa stroke cannot be excluded. Admit for MRI/MRA — and remember that MRI DWI may be falsely negative in the first 24–48 hours. Do not discharge with vestibular neuritis when the HINTS exam is central.
Bottom Line
The HINTS exam is more sensitive than early MRI for posterior fossa stroke in acute vestibular syndrome. A central HINTS pattern (normal head impulse, direction-changing nystagmus, or vertical skew) requires admission and neuroimaging — not a vestibular neuritis diagnosis.
EVIDENCE & REFERENCES
- Kattah JC, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-3510. doi:10.1161/STROKEAHA.109.551234
- Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. doi:10.1177/0194599816689667
- Strupp M, Brandt T. Vestibular neuritis. Semin Neurol. 2009;29(5):509-519. doi:10.1055/s-0029-1241040