EM · Vertigo and dizziness
Vertigo and dizziness
Also known as Acute vestibular syndrome · Peripheral vertigo · Central vertigo · BPPV · Vestibular neuritis
Vertigo and dizziness — the central-versus-peripheral distinction as the load-bearing decision, the HINTS examination (Head Impulse, Nystagmus, Test of Skew) for stroke in the acute vestibular syndrome, the Bárány diagnostic criteria and the Epley manoeuvre for BPPV, vestibular neuritis and labyrinthitis, Meniere disease, the differential (posterior-circulation TIA and stroke, vestibular migraine, cardiac syncope), and the drug doses (prochlorperazine 5 mg, corticosteroids). ACEM-primary, globally tagged.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
Red flags
- Acute vestibular syndrome with a CENTRAL HINTS pattern (normal head impulse test, direction-changing nystagmus, or skew deviation) is posterior-circulation stroke until proven otherwise — any one central sign is central
- A normal non-contrast CT does NOT exclude posterior-circulation stroke; the posterior fossa is beam-hardened and ischaemia is missed early — pursue MRI or admit to the stroke pathway
- Direction-fixed, unidirectional horizontal nystagmus that beats away from the affected ear with a positive (abnormal) head impulse test is the peripheral pattern of vestibular neuritis — but vertical, torsional-downbeat, or gaze-evoked direction-changing nystagmus is central
- Vestibular suppressants (prochlorperazine, diazepam) beyond a short three-day course delay central compensation in vestibular neuritis and must not be prescribed long-term
- New vertigo with hearing loss, otalgia and vesicles in the ear is Ramsay Hunt syndrome (varicella zoster) — urgent antivirals (aciclovir or famciclovir) plus steroids to protect facial nerve function and hearing
Meet the patient
A 68-year-old hypertensive man is brought in at 7am with twelve hours of continuous violent vertigo, vomiting, and a gait so unsteady his wife called an ambulance. He has spontaneous horizontal-torsional nystagmus and looks wretched. The registrar reaches for the prochlorperazine and the discharge letter labelled "vestibular neuritis."[1]
The single question that decides the next hour — and the one every Fellowship candidate is examined on — is whether his head impulse test, his nystagmus in lateral gaze, and his cover test say peripheral or central. Hold that question and everything below slots into place.[1]
References14ShowHide
- [1]Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging Stroke, 2009.PMID 19762709
- [2]Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome CMAJ, 2011.PMID 21576300
- [3]Tarnutzer AA, Gold D, Wang Z, et al. Impact of Clinician Training Background and Stroke Location on Bedside Diagnostic Test Accuracy in the Acute Vestibular Syndrome - A Meta-Analysis Ann Neurol, 2023.PMID 37038843
- [4]Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo Cochrane Database Syst Rev, 2014.PMID 25485940
- [5]Bogdanova A, Dlugaiczyk J, Heckmann JG, et al. Corticosteroids in patients with vestibular neuritis: An updated meta-analysis Acta Neurol Scand, 2022.PMID 36029039
- [6]Lopez-Escamez JA, Carey J, Chung WH, et al. Diagnostic criteria for Menière's disease J Vestib Res, 2015.PMID 25882471
- [7]von Brevern M, Bertholon P, Brandt T, et al. Benign paroxysmal positional vertigo: Diagnostic criteria J Vestib Res, 2015.PMID 26756126
- [8]Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis N Engl J Med, 2004.PMID 15269315
- [9]Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update) Otolaryngol Head Neck Surg, 2017.PMID 28248609
- [10]Staab JP, Eckhardt-Henn A, Horii A, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): Consensus document of the committee for the Classification of Vestibular Disorders of the Bárány Society J Vestib Res, 2017.PMID 29036855
- [11]Lempert T, Olesen J, Furman J, et al. [Vestibular migraine: diagnostic criteria: consensus document of the Bárány Society and the International Headache Society]. Nervenarzt, 2013.PMID 23532572
- [12]Popkirov S, Stone J, Holle-Lee D. Treatment of Persistent Postural-Perceptual Dizziness (PPPD) and Related Disorders Curr Treat Options Neurol, 2018.PMID 30315375
- [13]Newman-Toker DE, Curthoys IS, Halmagyi GM. Diagnosing Stroke in Acute Vertigo: The HINTS Family of Eye Movement Tests and the Future of the Eye ECG Semin Neurol, 2015.PMID 26444396
- [14]Saber Tehrani AS, Kattah JC, Mantokoudis G, et al. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms Neurology, 2014.PMID 24920847