← Diagnosis and Management Guides
Vertigo / Dizziness
Key considerations: Posterior circulation stroke, Cerebellar hemorrhage, Vertebral artery dissection
Cannot miss
- Posterior circulation stroke
- Cerebellar hemorrhage
- Vertebral artery dissection
Likely diagnoses
- BPPV
- Vestibular neuritis
- Meniere disease
- Vestibular migraine
- Central vertigo
Red flags
- Acute onset with vascular risk factors
- Inability to walk
- Direction-changing nystagmus
- New headache
- Skew deviation
- Negative HINTs exam
Workup
- history: Triggered by position vs constant, duration, hearing loss, recent illness, vascular risk factors; exam: HINTS exam (Head Impulse, Nystagmus, Test of Skew); Dix-Hallpike maneuver; Gait assessment, finger-to-nose; labs: Glucose, BMP (generally low yield); imaging: MRI with DWI if central vertigo suspected (CT misses posterior fossa strokes in 40%); bedside: HINTS exam is more sensitive than MRI in first 48hr for stroke detection
Management
- immediate: Central vertigo: stroke workup and treatment; BPPV: Epley or BBQ roll maneuver; general: Vestibular neuritis: short course methylprednisolone, vestibular exercises; Symptomatic: meclizine 25mg TID or ondansetron for nausea; Avoid vestibular suppressants long-term
Disposition
- admit: Central vertigo (stroke), inability to walk safely, intractable vomiting; discharge: BPPV after successful repositioning, vestibular neuritis with ability to function; consults: Neurology if central cause suspected, ENT for Meniere disease
Clinical pearls
- HINTS exam is 97% sensitive for stroke in acute vestibular syndrome — BETTER than early MRI
- BPPV: Dix-Hallpike positive = posterior canal (most common). Treat with Epley maneuver
- CT is inadequate for posterior fossa — always get MRI DWI if concerned about cerebellar stroke
Source and review
- AAN Vestibular Disorder Guidelines 2017. Last reviewed: 2024-11-01