VertigoAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

638 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Transient Neurologic Deficits Acute Aphasia And Speech Disturbance Acute Confusion And Delirium Postictal State And Seizure Recurrence Concern Seizure Acute Vision Loss New Tremor And Involuntary Movements Headache Vertigo Acute Weakness Or Numbness Gait Instability And Ataxia

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx77

HPI

›Symptom characterization

›Dizziness description

›Vertigo illusion of movement

›Presyncope lightheadedness

›Disequilibrium imbalance

›Nonspecific dizziness

›OPQRST

›Onset

›Sudden seconds to minutes

›Subacute hours

›Gradual days

›Provocation and palliation

›Triggered by head position change

›Triggered by head turning in bed

›Triggered by standing

›Triggered by exertion

›Triggered by loud sound

›Triggered by cough or Valsalva

›Relief with stillness

›Quality

›Spinning

›Tilting

›Rocking

›Floating

›Region and radiation

›Head pressure

›Neck pain

›Severity

›Unable to stand or walk

›Able to ambulate with support

›Timing

›Single prolonged episode

›Recurrent brief episodes

›Episodic spontaneous without triggers

›Trajectory

›Improving

›Static

›Worsening

›Associated symptoms

›Nausea

›Vomiting

›Hearing loss

›Tinnitus

›Aural fullness

›Headache

›Photophobia

›Phonophobia

›Diplopia

›Dysarthria

›Dysphagia

›Weakness

›Numbness

›Ataxia

›Syncope

›Palpitations

›Chest pain

›Dyspnea

›Fever

›Recent upper respiratory infection

›Prior episodes and baseline

›Similar episodes

›Baseline gait and balance

›Context

›Recent head trauma

›Recent ear infection

›Recent chiropractic manipulation or neck injury

›Recent long travel or dehydration

Timing and triggers pattern

›Syndrome framing

›Acute vestibular syndrome continuous hours to days

›Persistent vertigo

›Nausea or vomiting

›Episodic triggered vestibular syndrome seconds to minutes

›Position triggered

›Head movement triggered

›Episodic spontaneous vestibular syndrome minutes to hours

›No clear trigger

›Recurrent attacks

02Alarm Features/alarm41

Immediate escalation triggers

›High risk features

›Focal neurologic deficit

›Facial droop

›Limb weakness

›New sensory loss

›New severe headache

›Thunderclap onset

›Worst headache

›New inability to walk unassisted

›Truncal ataxia

›Falls

›Central eye findings

›Direction changing gaze evoked nystagmus

›Vertical or pure torsional nystagmus

›New skew deviation

›Severe neck pain with posterior circulation symptoms

›Suspected vertebral artery dissection

›Recent neck trauma or manipulation

›Fever with meningismus

›Encephalopathy

›Photophobia

›Head trauma with anticoagulation

›Intracranial hemorrhage concern

›Delayed bleed risk

›Persistent vomiting

›Dehydration

›Electrolyte derangement concern

›Unstable vital signs

›Hypotension

›Hypoxia

›Severe hypertension with neuro symptoms

Dangerous mimics

›Alternate life threats

›Acute coronary syndrome presentation variant

›Diaphoresis

›Chest pain equivalent

›Dysrhythmia or conduction disease

›Syncope

›Palpitations with hypotension

›Hypoglycemia

›Diaphoresis

›Altered mental status

03Medications/meds32

Exposure and iatrogenic causes

›Medication contributors

›Vestibular suppressants

›Recent use

›Prolonged use more than 72 hours

›Sedatives and psychoactive agents

›Benzodiazepines

›Opioids

›Antipsychotics

›Antihypertensives

›Recent dose change

›Orthostatic symptoms

›Ototoxic agents

›Aminoglycosides

›Loop diuretics

›Serotonergic agents

›SSRI

›SNRI

›Anticoagulants and antiplatelets

›Warfarin

›DOAC

›Aspirin

›Clopidogrel

Contraindications and interaction traps

›Safety checks before therapy

›QT prolongation risk

›Ondansetron

›Antipsychotics

›Anticholinergic burden

›Older adults delirium risk

›Urinary retention risk

›Pregnancy considerations

›Teratogenic exposures

›Preferred antiemetics local protocol dependent

04Diet/diet16

Intake and exposures

›Nutrition and fluid status

›Poor oral intake

›Duration

›Weight loss

›Dehydration risk

›Reduced fluids

›Diuretics

›Caffeine exposure

›Recent increase

›Energy drinks

›Alcohol exposure

›Recent binge

›Withdrawal symptoms

›High salt intake pattern

›Meniere symptom correlation

›Recent dietary change

05Review of Systems/ros33

Neurologic and otologic

›Key symptom screen

›Neurologic

›Diplopia

›Dysarthria

›Dysphagia

›Limb weakness

›Limb numbness

›Ataxia

›New severe headache

›Altered mental status

›Otologic

›Hearing loss

›Tinnitus

›Aural fullness

›Otalgia

›Autonomic and systemic

›Fever

›Diaphoresis

›Syncope

›Palpitations

›Chest pain

›Dyspnea

›Diarrhea or vomiting

Infectious and inflammatory

›Infection clues

›Upper respiratory symptoms

›Congestion

›Sore throat

›Ear infection symptoms

›Otorrhea

›Ear pain

›CNS infection symptoms

›Neck stiffness

›Photophobia

06Collateral History and Family History/chafh17

Sources and reliability

›Collateral inputs

›Witness description

›Syncope versus fall

›Seizure like activity

›Baseline function confirmation

›Usual gait

›Usual cognition

Hereditary risk

›Family history

›Early cerebrovascular disease

›Stroke before age 55

›Aneurysm history

›Migraine

›Vestibular migraine tendency

›Aura history

›Inner ear disorders

›Meniere disease

›Early hearing loss

07Risk Factors/rf32

Cerebrovascular risk

›Stroke and TIA risk

›Hypertension (I10)

›Poor control

›Medication nonadherence

›Diabetes mellitus type 2 (E11.9)

›Hypoglycemia episodes

›Hyperglycemia dehydration

›Hyperlipidemia (E78.5)

›Statin nonuse

›Prior vascular events

›Atrial fibrillation (I48.91)

›Anticoagulation status

›Rate control issues

›Smoking

›Current

›Heavy prior

›Prior stroke or TIA (I63.9) (G45.9)

›Posterior circulation history

›Residual deficits

Otologic and mechanical risk

›Peripheral vestibular risks

›Recent viral illness

›Vestibular neuritis association

›Dehydration

›Head trauma

›BPPV trigger

›Labyrinthine concussion

›Barotrauma

›Diving

›Air travel

›Sound or pressure induced symptoms

›Superior semicircular canal dehiscence concern

›Perilymph fistula concern

08Differential Diagnosis/ddx64

Life threatening

›Cannot miss diagnoses

›Ischemic stroke posterior circulation (I63.9)

›Acute vestibular syndrome with central eye findings

›New gait inability

›Transient ischemic attack (G45.9)

›Recurrent brief neuro symptoms

›High vascular risk

›Intracerebral hemorrhage (I61.9)

›Severe headache

›Anticoagulation

›Aneurysmal subarachnoid hemorrhage (I60.9)

›Thunderclap headache

›Meningismus

›Vertebral artery dissection (I77.74)

›Neck pain after trauma or manipulation

›Posterior circulation symptoms

›CNS infection meningitis or encephalitis (G03.9) (G04.90)

›Fever

›Neck stiffness or altered mental status

›Dysrhythmia with cerebral hypoperfusion (I49.9)

›Syncope

›Palpitations with hypotension

›Acute coronary syndrome atypical presentation (I21.9)

›Diaphoresis

›Chest pain equivalent

Common

›High frequency causes

›Benign paroxysmal positional vertigo (H81.1)

›Brief episodes seconds

›Triggered by position change

›Vestibular neuritis (H81.2)

›Acute vestibular syndrome after viral symptoms

›No hearing loss

›Labyrinthitis (H83.0)

›Acute vestibular syndrome

›Hearing loss present

›Meniere disease (H81.0)

›Episodic vertigo minutes to hours

›Fluctuating hearing loss

›Tinnitus or aural fullness

›Vestibular migraine (G43.809)

›Migraine history

›Photophobia or phonophobia

›Orthostatic hypotension (I95.1)

›Standing trigger

›Volume depletion or medication effect

›Medication adverse effect

›Sedatives

›Antihypertensives

Less common and zebras

›Lower frequency causes

›Superior semicircular canal dehiscence (H83.8)

›Sound induced vertigo

›Pressure induced vertigo

›Perilymph fistula (H83.1)

›Barotrauma

›Vertigo with exertion or pressure changes

›Acoustic neuroma vestibular schwannoma (D33.3)

›Progressive unilateral hearing loss

›Persistent imbalance

›Multiple sclerosis (G35)

›Recurrent neuro symptoms

›Young adult with new central signs

›Persistent postural perceptual dizziness (F45.8)

›Chronic dizziness

›Visual motion sensitivity

09Past Medical History/pmh26

Prior diagnoses and baseline

›Relevant conditions

›Prior vertigo syndromes

›Prior BPPV episodes

›Prior vestibular neuritis

›Migraine disorder (G43.909)

›Aura history

›Prior vestibular symptoms

›Cardiovascular disease

›Coronary artery disease (I25.10)

›Heart failure (I50.9)

›Cerebrovascular disease

›Prior stroke (I63.9)

›Prior TIA (G45.9)

›Recent infections

›Otitis media

›Sinusitis

›Baseline function

›Independent ambulation

›Baseline hearing status

Surgeries and devices

›Procedural history

›Ear surgery

›Tympanostomy tubes

›Mastoidectomy

›Cardiac devices

›Pacemaker

›ICD

10Physical Exam/exam46

Initial assessment

›General and vitals

›Appearance

›Toxic

›Comfortable at rest

›Vital sign patterns

›Fever

›Hypotension

›Severe hypertension

›Hypoxia

›Volume status

›Dry mucosa

›Poor skin turgor

Eye and neurologic

›Neuro otologic exam

›Mental status

›Orientation

›Attention

›Cranial nerves

›Pupils and visual fields

›Extraocular movements

›Facial symmetry

›Palate elevation

›Tongue deviation

›Nystagmus characterization

›Direction fixed horizontal torsional

›Direction changing gaze evoked

›Vertical

›Gait and balance

›Able to stand unaided

›Tandem gait

›Limb exam

›Pronator drift

›Strength symmetry

›Sensation symmetry

›Finger to nose

›Heel to shin

Cardiovascular and ENT

›System exams

›Cardiovascular

›Rate and rhythm

›Murmur

›ENT

›External ear and canal

›Tympanic membrane

›Hearing screen bedside

›Neck

›Meningismus

›Tenderness after trauma

11Lab Studies/labs23

Core tests when indicated

›Screening and targeted labs

›Point of care glucose

›Hypoglycemia threshold local protocol dependent

›Hyperglycemia dehydration concern

›Electrolytes

›Sodium derangements

›Potassium derangements

›CBC

›Infection marker context dependent

›Anemia contribution to presyncope

›Pregnancy test

›Reproductive age

›Imaging and medication implications

›Troponin

›Chest pain equivalent

›High risk cardiovascular symptoms

Interpretation pitfalls

›Limitations

›Normal labs do not exclude stroke

›Decision relies on exam and risk

›Imaging when high risk

›Dehydration and vomiting effects

›Metabolic alkalosis possible

›Hypokalemia possible

12Imaging/img44

Scoring Systems

›Risk tools when applicable

›NIHSS for suspected stroke

›Higher score increases stroke likelihood

›Posterior circulation stroke can have low NIHSS

›ABCD2 for suspected TIA

›Higher score increases early stroke risk

›Not validated for all dizziness presentations

›TiTrATE timing and triggers framework

›Acute vestibular syndrome versus episodic triggered versus episodic spontaneous

›Guides bedside testing selection

MRI

›MRI brain with DWI

›Indications

›Central eye findings on bedside exam

›New focal neurologic deficit

›High risk acute vestibular syndrome

›Limitations

›Early DWI false negative posterior fossa

›Repeat imaging if persistent high suspicion

›CT pathways

›Noncontrast CT head

›Indications

›Head trauma

›Severe headache

›Anticoagulation with head injury

›Limitations

›Low sensitivity for early ischemic posterior fossa infarct

›Normal CT does not exclude stroke

›CT angiography head and neck

›Indications

›Suspected dissection

›High risk posterior circulation stroke

›Contraindications and cautions

›Severe contrast allergy

›Kidney injury risk context dependent

Ultrasound

›Ultrasound adjuncts

›Carotid duplex when stroke workup

›Anterior circulation stenosis detection

›Limited for vertebral artery pathology

›POCUS volume status

›IVC assessment context dependent

›Dehydration support in vomiting

›Ocular ultrasound when visual symptoms

›Retinal detachment concern

›Vitreous hemorrhage concern

13Special Tests/spec24

Bedside vestibular maneuvers

›Positional testing

›Dix Hallpike

›Posterior canal BPPV diagnosis

›Torsional upbeating nystagmus pattern

›Supine roll test

›Horizontal canal BPPV diagnosis

›Geotropic versus apogeotropic patterns

Acute vestibular syndrome bedside eye exam

›HINTS exam in acute vestibular syndrome with spontaneous nystagmus

›Head impulse

›Abnormal suggests peripheral vestibulopathy

›Normal in severe vertigo suggests central cause

›Nystagmus

›Direction fixed horizontal suggests peripheral

›Direction changing suggests central

›Test of skew

›Vertical ocular misalignment suggests central

›New skew increases posterior circulation stroke concern

Orthostatic and cardiopulmonary testing

›System contributors

›Orthostatic vitals

›Sustained systolic drop suggests orthostatic hypotension

›Tachycardia response suggests volume depletion

›Ambulation test

›Severe gait ataxia suggests central

›Safe gait supports discharge criteria when peripheral likely

14ECG/ecg20

Rhythm and ischemia screen

›ECG indications

›Presyncope features

›Near fainting

›Palpitations

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›High risk patterns

›Atrial fibrillation

›Rapid ventricular response

›New diagnosis

›Bradyarrhythmia

›High grade AV block

›Sinus pauses

›QT prolongation

›Antiemetic and antipsychotic interaction risk

›Torsades risk context dependent

›Ischemic changes

›ST elevation

›New ST depression or T wave inversion

15Assessment/ax23

Problem representation

›Classification

›Acute vestibular syndrome

›Continuous vertigo hours to days

›Spontaneous nystagmus possible

›Episodic triggered vestibular syndrome

›Brief positional episodes

›BPPV likely when typical

›Episodic spontaneous vestibular syndrome

›Minutes to hours attacks

›Meniere or vestibular migraine consideration

Central versus peripheral likelihood

›Risk stratification synthesis

›Peripheral favored

›Typical BPPV positional triggers

›Unidirectional horizontal torsional nystagmus

›No focal neurologic deficits

›Central favored

›Direction changing or vertical nystagmus

›Severe truncal ataxia

›New focal neurologic deficits

›High vascular risk profile

›Diagnostic uncertainty

›Early posterior circulation stroke possible with subtle exam

›Repeat exam and imaging when high risk

16Plan/plan55

First 5 minutes critical patient workflow

›Stabilization priorities

›Airway and breathing

›Oxygen for hypoxia

›Aspiration risk with ongoing vomiting

›Circulation

›IV access if persistent vomiting or dehydration

›Fluids for hypotension or volume depletion

›Monitoring

›Cardiac monitor for syncope or palpitations

›Frequent vitals for unstable patients

›Time critical stroke pathway

›If new focal deficit immediate stroke activation local protocol dependent

›If acute vestibular syndrome with central signs treat as stroke until proven otherwise

Diagnostic sequencing

›Testing logic

›If acute vestibular syndrome with nystagmus

›HINTS by trained clinician

›MRI DWI or CTA when central suspected

›If episodic triggered positional

›Dix Hallpike

›Treat with canalith repositioning if positive

›If presyncope phenotype

›ECG

›Orthostatic vitals

Symptom control and targeted therapy

›Medications and maneuvers

›Antiemetics

›Ondansetron PO or ODT 4 mg

›Ondansetron IV 4 mg

›QT prolongation risk check

›Vestibular suppressants short course when severe nausea or vomiting

›Meclizine PO 25 mg

›Dimenhydrinate PO 50 mg

›Avoid prolonged use more than 72 hours if possible

›BPPV treatment

›Epley maneuver for posterior canal

›Symptom relief expected within days

›Vestibular neuritis treatment context dependent

›Steroids within 72 hours possible benefit local protocol dependent

›Early vestibular rehab exercises after acute phase

›Vestibular migraine treatment

›Prochlorperazine PO 10 mg

›Metoclopramide IV 10 mg

›IV fluids if dehydrated

›Suspected stroke or TIA

›Antiplatelet therapy per protocol when hemorrhage excluded

›Thrombolysis and thrombectomy eligibility per local stroke protocol

Reassessment loop

›Iterative checks

›Symptom trajectory

›Improvement after fluids or antiemetic

›Persistent severe vertigo despite therapy

›Repeat neurologic exam

›New focal deficits

›Gait safety reassessment

›Repeat eye findings when uncertain

›Nystagmus evolution

›New skew

17Disposition/dispo36

Level of care criteria

›ICU or high acuity

›Stroke with airway risk

›Reduced consciousness

›Refractory vomiting with aspiration risk

›Hemodynamic instability

›Persistent hypotension

›Malignant arrhythmia

›Intracranial hemorrhage concern

›Severe headache with neuro decline

›Anticoagulation with head trauma

Admission and observation

›Inpatient or observation indications

›Suspected central cause

›Abnormal HINTS central pattern

›Focal neurologic deficits

›High risk TIA features

›Recurrent symptoms

›High ABCD2 score

›Intractable vomiting or dehydration

›Electrolyte derangements

›Unable to tolerate PO

›Unsafe ambulation

›Falls risk

›No reliable support at home

Discharge criteria

›Safe discharge requirements

›Peripheral diagnosis likely

›Typical BPPV with response to maneuver

›Vestibular neuritis without central signs and stable exam

›Stable vitals

›No hypotension

›No hypoxia

›Safe gait

›Ambulates independently or with baseline device

›No truncal ataxia

›Oral intake adequate

›Tolerates fluids

›Antiemetic effectiveness

18Discharge Instructions/di22

Copy discharge instructions

›Diagnosis and expectations

›Symptoms most consistent with a peripheral vertigo syndrome

›Severe or persistent symptoms can occasionally indicate a stroke and require urgent reassessment

›Medications

›Take anti nausea medication as prescribed

›Avoid sedating medications when driving or operating machinery

›Activity and safety

›No driving until dizziness resolves

›Change positions slowly

›Use support when walking if unsteady

›Follow up

›Primary care follow up within 2 to 3 days

›ENT or vestibular therapy follow up if symptoms persist more than 1 to 2 weeks

›Return to ED immediately for

›New weakness or numbness

›New trouble speaking or swallowing

›New double vision

›New severe headache

›Fainting

›Inability to walk

›Persistent vomiting despite medication

›Fever with neck stiffness

19References/r7

Guidelines and key evidence

›Core sources

›GRACE 3 acute dizziness and vertigo in the emergency department 2023

›AAO HNSF clinical practice guideline benign paroxysmal positional vertigo update 2017

›AHA ASA guidelines for early management of acute ischemic stroke 2019 update

›AHA ASA guideline for management of spontaneous intracerebral hemorrhage 2022

›AHA ASA guideline for management of aneurysmal subarachnoid hemorrhage 2023

›Kattah et al HINTS to diagnose stroke in acute vestibular syndrome 2009

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

VertigoAPPROACH

NEUROLOGIC · 19 SECTIONS

⚲

638 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx77

HPI

›Symptom characterization

›Dizziness description

›Vertigo illusion of movement

›Presyncope lightheadedness

›Disequilibrium imbalance

›Nonspecific dizziness

›OPQRST

›Onset

›Sudden seconds to minutes

›Subacute hours

›Gradual days

›Provocation and palliation

›Triggered by head position change

›Triggered by head turning in bed

›Triggered by standing

›Triggered by exertion

›Triggered by loud sound

›Triggered by cough or Valsalva

›Relief with stillness

›Quality

›Spinning

›Tilting

›Rocking

›Floating

›Region and radiation

›Head pressure

›Neck pain

›Severity

›Unable to stand or walk

›Able to ambulate with support

›Timing

›Single prolonged episode

›Recurrent brief episodes

›Episodic spontaneous without triggers

›Trajectory

›Improving

›Static

›Worsening

›Associated symptoms

›Nausea

›Vomiting

›Hearing loss

›Tinnitus

›Aural fullness

›Headache

›Photophobia

›Phonophobia

›Diplopia

›Dysarthria

›Dysphagia

›Weakness

›Numbness

›Ataxia

›Syncope

›Palpitations

›Chest pain

›Dyspnea

›Fever

›Recent upper respiratory infection

›Prior episodes and baseline

›Similar episodes

›Baseline gait and balance

›Context

›Recent head trauma

›Recent ear infection

›Recent chiropractic manipulation or neck injury

›Recent long travel or dehydration

Timing and triggers pattern

›Syndrome framing

›Acute vestibular syndrome continuous hours to days

›Persistent vertigo

›Nausea or vomiting

›Episodic triggered vestibular syndrome seconds to minutes

›Position triggered

›Head movement triggered

›Episodic spontaneous vestibular syndrome minutes to hours

›No clear trigger

›Recurrent attacks

02Alarm Features/alarm41

Immediate escalation triggers

›High risk features

›Focal neurologic deficit

›Facial droop

›Limb weakness

›New sensory loss

›New severe headache

›Thunderclap onset

›Worst headache

›New inability to walk unassisted

›Truncal ataxia

›Falls

›Central eye findings

›Direction changing gaze evoked nystagmus

›Vertical or pure torsional nystagmus

›New skew deviation

›Severe neck pain with posterior circulation symptoms

›Suspected vertebral artery dissection

›Recent neck trauma or manipulation

›Fever with meningismus

›Encephalopathy

›Photophobia

›Head trauma with anticoagulation

›Intracranial hemorrhage concern

›Delayed bleed risk

›Persistent vomiting

›Dehydration

›Electrolyte derangement concern

›Unstable vital signs

›Hypotension

›Hypoxia

›Severe hypertension with neuro symptoms

Dangerous mimics

›Alternate life threats

›Acute coronary syndrome presentation variant

›Diaphoresis

›Chest pain equivalent

›Dysrhythmia or conduction disease

›Syncope

›Palpitations with hypotension

›Hypoglycemia

›Diaphoresis

›Altered mental status

03Medications/meds32

Exposure and iatrogenic causes

›Medication contributors

›Vestibular suppressants

›Recent use

›Prolonged use more than 72 hours

›Sedatives and psychoactive agents

›Benzodiazepines

›Opioids

›Antipsychotics

›Antihypertensives

›Recent dose change

›Orthostatic symptoms

›Ototoxic agents

›Aminoglycosides

›Loop diuretics

›Serotonergic agents

›SSRI

›SNRI

›Anticoagulants and antiplatelets

›Warfarin

›DOAC

›Aspirin

›Clopidogrel

Contraindications and interaction traps

›Safety checks before therapy

›QT prolongation risk

›Ondansetron

›Antipsychotics

›Anticholinergic burden

›Older adults delirium risk

›Urinary retention risk

›Pregnancy considerations

›Teratogenic exposures

›Preferred antiemetics local protocol dependent

04Diet/diet16

Intake and exposures

›Nutrition and fluid status

›Poor oral intake

›Duration

›Weight loss

›Dehydration risk

›Reduced fluids

›Diuretics

›Caffeine exposure

›Recent increase

›Energy drinks

›Alcohol exposure

›Recent binge

›Withdrawal symptoms

›High salt intake pattern

›Meniere symptom correlation

›Recent dietary change

05Review of Systems/ros33

Neurologic and otologic

›Key symptom screen

›Neurologic

›Diplopia

›Dysarthria

›Dysphagia

›Limb weakness

›Limb numbness

›Ataxia

›New severe headache

›Altered mental status

›Otologic

›Hearing loss

›Tinnitus

›Aural fullness

›Otalgia

›Autonomic and systemic

›Fever

›Diaphoresis

›Syncope

›Palpitations

›Chest pain

›Dyspnea

›Diarrhea or vomiting

Infectious and inflammatory

›Infection clues

›Upper respiratory symptoms

›Congestion

›Sore throat

›Ear infection symptoms

›Otorrhea

›Ear pain

›CNS infection symptoms

›Neck stiffness

›Photophobia

06Collateral History and Family History/chafh17

Sources and reliability

›Collateral inputs

›Witness description

›Syncope versus fall

›Seizure like activity

›Baseline function confirmation

›Usual gait

›Usual cognition

Hereditary risk

›Family history

›Early cerebrovascular disease

›Stroke before age 55

›Aneurysm history

›Migraine

›Vestibular migraine tendency

›Aura history

›Inner ear disorders

›Meniere disease

›Early hearing loss

07Risk Factors/rf32

Cerebrovascular risk

›Stroke and TIA risk

›Hypertension (I10)

›Poor control

›Medication nonadherence

›Diabetes mellitus type 2 (E11.9)

›Hypoglycemia episodes

›Hyperglycemia dehydration

›Hyperlipidemia (E78.5)

›Statin nonuse

›Prior vascular events

›Atrial fibrillation (I48.91)

›Anticoagulation status

›Rate control issues

›Smoking

›Current

›Heavy prior

›Prior stroke or TIA (I63.9) (G45.9)

›Posterior circulation history

›Residual deficits

Otologic and mechanical risk

›Peripheral vestibular risks

›Recent viral illness

›Vestibular neuritis association

›Dehydration

›Head trauma

›BPPV trigger

›Labyrinthine concussion

›Barotrauma

›Diving

›Air travel

›Sound or pressure induced symptoms

›Superior semicircular canal dehiscence concern

›Perilymph fistula concern

08Differential Diagnosis/ddx64

Life threatening

›Cannot miss diagnoses

›Ischemic stroke posterior circulation (I63.9)

›Acute vestibular syndrome with central eye findings

›New gait inability

›Transient ischemic attack (G45.9)

›Recurrent brief neuro symptoms

›High vascular risk

›Intracerebral hemorrhage (I61.9)

›Severe headache

›Anticoagulation

›Aneurysmal subarachnoid hemorrhage (I60.9)

›Thunderclap headache

›Meningismus

›Vertebral artery dissection (I77.74)

›Neck pain after trauma or manipulation

›Posterior circulation symptoms

›CNS infection meningitis or encephalitis (G03.9) (G04.90)

›Fever

›Neck stiffness or altered mental status

›Dysrhythmia with cerebral hypoperfusion (I49.9)

›Syncope

›Palpitations with hypotension

›Acute coronary syndrome atypical presentation (I21.9)

›Diaphoresis

›Chest pain equivalent

Common

›High frequency causes

›Benign paroxysmal positional vertigo (H81.1)

›Brief episodes seconds

›Triggered by position change

›Vestibular neuritis (H81.2)

›Acute vestibular syndrome after viral symptoms

›No hearing loss

›Labyrinthitis (H83.0)

›Acute vestibular syndrome

›Hearing loss present

›Meniere disease (H81.0)

›Episodic vertigo minutes to hours

›Fluctuating hearing loss

›Tinnitus or aural fullness

›Vestibular migraine (G43.809)

›Migraine history

›Photophobia or phonophobia

›Orthostatic hypotension (I95.1)

›Standing trigger

›Volume depletion or medication effect

›Medication adverse effect

›Sedatives

›Antihypertensives

Less common and zebras

›Lower frequency causes

›Superior semicircular canal dehiscence (H83.8)

›Sound induced vertigo

›Pressure induced vertigo

›Perilymph fistula (H83.1)

›Barotrauma

›Vertigo with exertion or pressure changes

›Acoustic neuroma vestibular schwannoma (D33.3)

›Progressive unilateral hearing loss

›Persistent imbalance

›Multiple sclerosis (G35)

›Recurrent neuro symptoms

›Young adult with new central signs

›Persistent postural perceptual dizziness (F45.8)

›Chronic dizziness

›Visual motion sensitivity

09Past Medical History/pmh26

Prior diagnoses and baseline

›Relevant conditions

›Prior vertigo syndromes

›Prior BPPV episodes

›Prior vestibular neuritis

›Migraine disorder (G43.909)

›Aura history

›Prior vestibular symptoms

›Cardiovascular disease

›Coronary artery disease (I25.10)

›Heart failure (I50.9)

›Cerebrovascular disease

›Prior stroke (I63.9)

›Prior TIA (G45.9)

›Recent infections

›Otitis media

›Sinusitis

›Baseline function

›Independent ambulation

›Baseline hearing status

Surgeries and devices

›Procedural history

›Ear surgery

›Tympanostomy tubes

›Mastoidectomy

›Cardiac devices

›Pacemaker

›ICD

10Physical Exam/exam46

Initial assessment

›General and vitals

›Appearance

›Toxic

›Comfortable at rest

›Vital sign patterns

›Fever

›Hypotension

›Severe hypertension

›Hypoxia

›Volume status

›Dry mucosa

›Poor skin turgor

Eye and neurologic

›Neuro otologic exam

›Mental status

›Orientation

›Attention

›Cranial nerves

›Pupils and visual fields

›Extraocular movements

›Facial symmetry

›Palate elevation

›Tongue deviation

›Nystagmus characterization

›Direction fixed horizontal torsional

›Direction changing gaze evoked

›Vertical

›Gait and balance

›Able to stand unaided

›Tandem gait

›Limb exam

›Pronator drift

›Strength symmetry

›Sensation symmetry

›Finger to nose

›Heel to shin

Cardiovascular and ENT

›System exams

›Cardiovascular

›Rate and rhythm

›Murmur

›ENT

›External ear and canal

›Tympanic membrane

›Hearing screen bedside

›Neck

›Meningismus

›Tenderness after trauma

11Lab Studies/labs23

Core tests when indicated

›Screening and targeted labs

›Point of care glucose

›Hypoglycemia threshold local protocol dependent

›Hyperglycemia dehydration concern

›Electrolytes

›Sodium derangements

›Potassium derangements

›CBC

›Infection marker context dependent

›Anemia contribution to presyncope

›Pregnancy test

›Reproductive age

›Imaging and medication implications

›Troponin

›Chest pain equivalent

›High risk cardiovascular symptoms

Interpretation pitfalls

›Limitations

›Normal labs do not exclude stroke

›Decision relies on exam and risk

›Imaging when high risk

›Dehydration and vomiting effects

›Metabolic alkalosis possible

›Hypokalemia possible

12Imaging/img44

Scoring Systems

›Risk tools when applicable

›NIHSS for suspected stroke

›Higher score increases stroke likelihood

›Posterior circulation stroke can have low NIHSS

›ABCD2 for suspected TIA

›Higher score increases early stroke risk

›Not validated for all dizziness presentations

›TiTrATE timing and triggers framework

›Acute vestibular syndrome versus episodic triggered versus episodic spontaneous

›Guides bedside testing selection

MRI

›MRI brain with DWI

›Indications

›Central eye findings on bedside exam

›New focal neurologic deficit

›High risk acute vestibular syndrome

›Limitations

›Early DWI false negative posterior fossa

›Repeat imaging if persistent high suspicion

›CT pathways

›Noncontrast CT head

›Indications

›Head trauma

›Severe headache

›Anticoagulation with head injury

›Limitations

›Low sensitivity for early ischemic posterior fossa infarct

›Normal CT does not exclude stroke

›CT angiography head and neck

›Indications

›Suspected dissection

›High risk posterior circulation stroke

›Contraindications and cautions

›Severe contrast allergy

›Kidney injury risk context dependent

Ultrasound

›Ultrasound adjuncts

›Carotid duplex when stroke workup

›Anterior circulation stenosis detection

›Limited for vertebral artery pathology

›POCUS volume status

›IVC assessment context dependent

›Dehydration support in vomiting

›Ocular ultrasound when visual symptoms

›Retinal detachment concern

›Vitreous hemorrhage concern

13Special Tests/spec24

Bedside vestibular maneuvers

›Positional testing

›Dix Hallpike

›Posterior canal BPPV diagnosis

›Torsional upbeating nystagmus pattern

›Supine roll test

›Horizontal canal BPPV diagnosis

›Geotropic versus apogeotropic patterns

Acute vestibular syndrome bedside eye exam

›HINTS exam in acute vestibular syndrome with spontaneous nystagmus

›Head impulse

›Abnormal suggests peripheral vestibulopathy

›Normal in severe vertigo suggests central cause

›Nystagmus

›Direction fixed horizontal suggests peripheral

›Direction changing suggests central

›Test of skew

›Vertical ocular misalignment suggests central

›New skew increases posterior circulation stroke concern

Orthostatic and cardiopulmonary testing

›System contributors

›Orthostatic vitals

›Sustained systolic drop suggests orthostatic hypotension

›Tachycardia response suggests volume depletion

›Ambulation test

›Severe gait ataxia suggests central

›Safe gait supports discharge criteria when peripheral likely

14ECG/ecg20

Rhythm and ischemia screen

›ECG indications

›Presyncope features

›Near fainting

›Palpitations

›Cardiopulmonary symptoms

›Chest pain

›Dyspnea

›High risk patterns

›Atrial fibrillation

›Rapid ventricular response

›New diagnosis

›Bradyarrhythmia

›High grade AV block

›Sinus pauses

›QT prolongation

›Antiemetic and antipsychotic interaction risk

›Torsades risk context dependent

›Ischemic changes

›ST elevation

›New ST depression or T wave inversion

15Assessment/ax23

Problem representation

›Classification

›Acute vestibular syndrome

›Continuous vertigo hours to days

›Spontaneous nystagmus possible

›Episodic triggered vestibular syndrome

›Brief positional episodes

›BPPV likely when typical

›Episodic spontaneous vestibular syndrome

›Minutes to hours attacks

›Meniere or vestibular migraine consideration

Central versus peripheral likelihood

›Risk stratification synthesis

›Peripheral favored

›Typical BPPV positional triggers

›Unidirectional horizontal torsional nystagmus

›No focal neurologic deficits

›Central favored

›Direction changing or vertical nystagmus

›Severe truncal ataxia

›New focal neurologic deficits

›High vascular risk profile

›Diagnostic uncertainty

›Early posterior circulation stroke possible with subtle exam

›Repeat exam and imaging when high risk

16Plan/plan55

First 5 minutes critical patient workflow

›Stabilization priorities

›Airway and breathing

›Oxygen for hypoxia

›Aspiration risk with ongoing vomiting

›Circulation

›IV access if persistent vomiting or dehydration

›Fluids for hypotension or volume depletion

›Monitoring

›Cardiac monitor for syncope or palpitations

›Frequent vitals for unstable patients

›Time critical stroke pathway

›If new focal deficit immediate stroke activation local protocol dependent

›If acute vestibular syndrome with central signs treat as stroke until proven otherwise

Diagnostic sequencing

›Testing logic

›If acute vestibular syndrome with nystagmus

›HINTS by trained clinician

›MRI DWI or CTA when central suspected

›If episodic triggered positional

›Dix Hallpike

›Treat with canalith repositioning if positive

›If presyncope phenotype

›ECG

›Orthostatic vitals

Symptom control and targeted therapy

›Medications and maneuvers

›Antiemetics

›Ondansetron PO or ODT 4 mg

›Ondansetron IV 4 mg

›QT prolongation risk check

›Vestibular suppressants short course when severe nausea or vomiting

›Meclizine PO 25 mg

›Dimenhydrinate PO 50 mg

›Avoid prolonged use more than 72 hours if possible

›BPPV treatment

›Epley maneuver for posterior canal

›Symptom relief expected within days

›Vestibular neuritis treatment context dependent

›Steroids within 72 hours possible benefit local protocol dependent

›Early vestibular rehab exercises after acute phase

›Vestibular migraine treatment

›Prochlorperazine PO 10 mg

›Metoclopramide IV 10 mg

›IV fluids if dehydrated

›Suspected stroke or TIA

›Antiplatelet therapy per protocol when hemorrhage excluded

›Thrombolysis and thrombectomy eligibility per local stroke protocol

Reassessment loop

›Iterative checks

›Symptom trajectory

›Improvement after fluids or antiemetic

›Persistent severe vertigo despite therapy

›Repeat neurologic exam

›New focal deficits

›Gait safety reassessment

›Repeat eye findings when uncertain

›Nystagmus evolution

›New skew

17Disposition/dispo36

Level of care criteria

›ICU or high acuity

›Stroke with airway risk

›Reduced consciousness

›Refractory vomiting with aspiration risk

›Hemodynamic instability

›Persistent hypotension

›Malignant arrhythmia

›Intracranial hemorrhage concern

›Severe headache with neuro decline

›Anticoagulation with head trauma

Admission and observation

›Inpatient or observation indications

›Suspected central cause

›Abnormal HINTS central pattern

›Focal neurologic deficits

›High risk TIA features

›Recurrent symptoms

›High ABCD2 score

›Intractable vomiting or dehydration

›Electrolyte derangements

›Unable to tolerate PO

›Unsafe ambulation

›Falls risk

›No reliable support at home

Discharge criteria

›Safe discharge requirements

›Peripheral diagnosis likely

›Typical BPPV with response to maneuver

›Vestibular neuritis without central signs and stable exam

›Stable vitals

›No hypotension

›No hypoxia

›Safe gait

›Ambulates independently or with baseline device

›No truncal ataxia

›Oral intake adequate

›Tolerates fluids

›Antiemetic effectiveness

18Discharge Instructions/di22

Copy discharge instructions

›Diagnosis and expectations

›Symptoms most consistent with a peripheral vertigo syndrome

›Severe or persistent symptoms can occasionally indicate a stroke and require urgent reassessment

›Medications

›Take anti nausea medication as prescribed

›Avoid sedating medications when driving or operating machinery

›Activity and safety

›No driving until dizziness resolves

›Change positions slowly

›Use support when walking if unsteady

›Follow up

›Primary care follow up within 2 to 3 days

›ENT or vestibular therapy follow up if symptoms persist more than 1 to 2 weeks

›Return to ED immediately for

›New weakness or numbness

›New trouble speaking or swallowing

›New double vision

›New severe headache

›Fainting

›Inability to walk

›Persistent vomiting despite medication

›Fever with neck stiffness

19References/r7

Guidelines and key evidence

›Core sources

›GRACE 3 acute dizziness and vertigo in the emergency department 2023

›AAO HNSF clinical practice guideline benign paroxysmal positional vertigo update 2017

›AHA ASA guidelines for early management of acute ischemic stroke 2019 update

›AHA ASA guideline for management of spontaneous intracerebral hemorrhage 2022

›AHA ASA guideline for management of aneurysmal subarachnoid hemorrhage 2023

›Kattah et al HINTS to diagnose stroke in acute vestibular syndrome 2009

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.