Dizziness accounts for approximately 3%–5% of all ED visits and over 7 million ambulatory visits annually in the US. [1-2] Roughly half of ED patients with dizziness have general medical conditions, 33% have peripheral vestibular causes, and ~11% have neurological etiologies (of which about one-third are cerebrovascular). [3] The critical challenge is distinguishing the ~3%–6% with serious central causes (primarily stroke) from the vast majority with benign etiologies. [3-4] Modern diagnostic paradigms emphasize timing, triggers, and targeted examination (TiTrATE) rather than subjective symptom descriptors, as approximately half of patients change their symptom description during their ED stay. [2][5]
The following diagnostic algorithm from the AAFP illustrates the TiTrATE approach:
1. History
- Timing is the single most important branch point: Is the dizziness episodic (seconds to minutes) or continuous/persistent (hours to days)? [2][5]
- Triggers: Positional (head turning, rolling in bed → BPPV), standing (orthostatic hypotension), Valsalva, spontaneous onset without trigger (vestibular neuritis, stroke, vestibular migraine, Meniere disease) [5]
- Symptom quality is unreliable — ~60% of patients report more than one descriptor (vertigo, lightheadedness, imbalance, presyncope), and ~50% change their description during the visit [2]
- Associated symptoms: Hearing loss/tinnitus (Meniere, labyrinthitis, AICA stroke), headache (migraine, SAH, dissection), chest pain/palpitations (cardiac), diplopia/dysarthria/dysphagia/dysmetria/dysesthesia ("deadly Ds" → central cause) [3]
- Important negatives: No focal neurologic deficits, no recent head trauma, no new medications, no fever, no chest pain, no dyspnea
2. Alarm Features
- "Deadly Ds": Diplopia, dysarthria, dysphagia, dysphonia, dysmetria, dysesthesia — any suggests central etiology [3]
- Acute onset continuous dizziness with nausea/vomiting, nystagmus, and gait instability (acute vestibular syndrome) — up to 25% of AVS patients may have cerebellar infarction [1]
- Inability to walk or stand independently — strongly associated with central cause [3]
- New-onset severe headache with dizziness — consider SAH, vertebral artery dissection
- Abnormal vital signs: Significant bradycardia/tachycardia, irregular pulse, hypotension, hypoxia, or severe hypertension [3]
- New hearing loss in the setting of AVS — increases concern for AICA stroke (HINTS Plus) [6]
- Do not rely on the absence of limb ataxia or focal signs to exclude stroke — HINTS outperforms these findings [5]
3. Medications
- Common contributors to dizziness: [5][7-8]
- Antihypertensives (especially alpha-blockers, diuretics, beta-blockers)
- Psychoactive medications (benzodiazepines, SSRIs, TCAs, antipsychotics, opioids)
- Anticonvulsants (gabapentin, pregabalin)
- Aminoglycosides (ototoxicity)
- Anticholinergics (sedation, orthostatic hypotension)
- Antidiabetic agents (hypoglycemia)
- Alcohol
- Treatment medications:
- Vestibular suppressants (meclizine, diazepam, scopolamine) — use only short-term (several days); longer use inhibits central compensation [3]
- Meclizine is not effective for BPPV and should not be used as primary treatment [3][9]
- The American Geriatric Society recommends against meclizine in older adults due to anticholinergic effects [3]
- Temporal relationship between medication initiation/dose change and symptom onset should always be investigated [7]
4. Diet
- Meniere disease: Low-sodium diet (< 2 g/day) is a standard recommendation to reduce endolymphatic hydrops
- Dehydration/volume depletion: Common and easily reversible cause of presyncope/lightheadedness — assess oral intake, especially in elderly and those on diuretics
- Alcohol: Acute cerebellar toxicity; chronic use associated with vestibular dysfunction
- Caffeine: May exacerbate vestibular migraine in susceptible individuals
- Hypoglycemia: Assess recent oral intake in diabetic patients on insulin or sulfonylureas
5. Review of Systems
- Neurologic: Headache, visual changes, diplopia, facial numbness/weakness, limb weakness, speech difficulty, swallowing difficulty
- Cardiac: Palpitations, chest pain, exertional dyspnea, syncope/near-syncope
- ENT: Hearing loss, tinnitus, aural fullness, ear pain, recent URI
- Psychiatric: Anxiety, panic attacks, hyperventilation, agoraphobia (persistent postural-perceptual dizziness)
- General: Fever, weight loss, recent illness, dehydration, pregnancy
6. Collateral History and Family History
- Witnesses to the event — was there loss of consciousness (syncope vs. dizziness)?
- Medication list from family/pharmacy — polypharmacy is a major contributor, especially in the elderly [10]
- Family history of migraine (vestibular migraine), sudden cardiac death, arrhythmia syndromes (long QT, Brugada, HCM), Meniere disease
- Social context: Fall risk at home, ability to ambulate safely, living alone
7. Risk Factors
- For stroke in dizzy patients: [3][11]
- Age > 65, male sex
- Hypertension, diabetes, atrial fibrillation
- Prior stroke/TIA
- The Sudbury Vertigo Risk Score (7-item model including age >65, male, HTN, DM, motor/sensory deficits, cerebellar signs, and absence of BPPV diagnosis) achieved a C-statistic of 0.96 for serious diagnosis [11]
- For BPPV: Female sex, older age, prior head trauma, prolonged bed rest, osteoporosis, vitamin D deficiency [9]
- For orthostatic hypotension: Polypharmacy, autonomic neuropathy (diabetes, Parkinson disease), dehydration, adrenal insufficiency [8]
- For vestibular migraine: Personal/family history of migraine, female sex
8. Differential Diagnosis
The differential is organized by the TiTrATE framework: [5]
Triggered Episodic Vestibular Syndrome
- BPPV — most common peripheral cause (~40% of vestibular diagnoses); brief episodes (< 1 min) triggered by position changes [9][12]
- Orthostatic hypotension — triggered by standing; SBP drop ≥ 20 mmHg or DBP ≥ 10 mmHg within 3 minutes [5]
Spontaneous Episodic Vestibular Syndrome
- Vestibular migraine — recurrent spontaneous vertigo with migraine features
- Meniere disease — vertigo episodes 20 min–12 hours with hearing loss, tinnitus, aural fullness
- TIA (posterior circulation) — cannot-miss diagnosis
- Cardiac arrhythmia — palpitations, presyncope, syncope
- Panic disorder — associated with hyperventilation, anxiety
Acute Vestibular Syndrome (Continuous)
- Vestibular neuritis — most common peripheral cause of AVS
- Posterior circulation stroke (cerebellar, brainstem) — cannot-miss; 10%–20% of AVS is cerebrovascular [5]
- Intracranial hemorrhage — uncommon cause of isolated dizziness but must be considered [3]
- Labyrinthitis — vestibular neuritis + hearing loss
General Medical Causes (~50% of all ED dizziness)
9. Past Medical History
- Prior episodes of dizziness or vertigo (recurrence pattern)
- History of migraine, Meniere disease, prior BPPV
- Cardiovascular disease: atrial fibrillation, heart failure, valvular disease
- Neurologic disease: prior stroke/TIA, multiple sclerosis, Parkinson disease
- Diabetes (autonomic neuropathy, hypoglycemia)
- Psychiatric history: anxiety, panic disorder
- Recent surgery or prolonged immobilization (BPPV risk)
- Ear surgery, chronic ear disease
10. Physical Exam
- Vital signs: Orthostatic blood pressure and heart rate (supine → standing at 1 and 3 minutes); pulse regularity; oxygen saturation [5]
- Nystagmus assessment: Direction, persistence, effect of gaze fixation — unidirectional horizontal nystagmus suppressed by fixation suggests peripheral; bidirectional, vertical, or direction-changing nystagmus suggests central [6][13]
- HINTS exam (for AVS with spontaneous nystagmus only): [1][6][14]
- Head Impulse test — normal (no corrective saccade) = concerning for central
- Nystagmus — direction-changing = central
- Test of Skew — vertical skew deviation = central
- Sensitivity 92%–100%, specificity 81%–86% for stroke when performed by trained clinicians [6][14-15]
- HINTS Plus: Add finger-rub hearing test — new unilateral hearing loss increases sensitivity to ~99% [6][15]
- Dix-Hallpike maneuver: For triggered episodic dizziness — transient upbeat-torsional nystagmus with latency confirms posterior canal BPPV [5]
- Gait assessment: Inability to stand or walk independently is a red flag for central cause [3][6]
- Cerebellar exam: Finger-to-nose, heel-to-shin, rapid alternating movements — dysmetria has 97.8% specificity for central cause [6]
- General neurologic exam: Cranial nerves, motor/sensory, speech
11. Lab Studies
- Not routinely required for most patients with dizziness [5]
- Consider based on clinical suspicion:
- Fingerstick glucose — rule out hypoglycemia
- CBC — anemia
- BMP — electrolyte abnormalities, renal function, dehydration
- TSH — thyroid dysfunction (if chronic/recurrent)
- Pregnancy test — reproductive-age women
- Troponin — only if cardiac ischemia suspected; avoid routine use in elderly with nonspecific dizziness (high false-positive rate) [5]
12. Imaging
- CT head: Not recommended as a first-line test for dizziness — sensitivity for posterior fossa ischemic stroke is only ~16%–28%. CT may be reasonable if hemorrhage is suspected (severe headache, anticoagulation) but a negative CT should not be reassuring for ischemic stroke [3][16]
- MRI with DWI: Gold standard for posterior fossa stroke, but sensitivity is imperfect early (may miss ~50% of small posterior fossa strokes within 48 hours). Pooled diagnostic yield of MRI in ED dizziness patients is ~13%; for isolated dizziness only ~4%–6% [2][16-17]
- Per GRACE-3 guidelines: [3][3]
- Do not use CT to evaluate for stroke in dizzy patients
- Do not use routine MRI as first-line if a HINTS-trained clinician is available
- Use MRI as a confirmatory test when HINTS is central or equivocal
- Consider CTA/MRA if TIA or vertebral artery dissection is suspected
- ACR Appropriateness Criteria: For nonspecific dizziness without neurologic deficits, imaging is usually not indicated [2]
13. Special Tests
- Dix-Hallpike maneuver: Diagnostic for posterior canal BPPV (sensitivity ~80%, specificity ~90%) [5][9]
- HINTS / HINTS Plus: Best bedside test for AVS — outperforms early MRI for stroke detection when performed by trained clinicians [1]
- STANDING algorithm: Alternative to HINTS with comparable sensitivity (94%) and better specificity (75%) [12]
- Sudbury Vertigo Risk Score: 7-item clinical prediction rule for serious diagnosis (C-statistic 0.96); score < 5 = 0% risk of serious diagnosis [11]
- Audiometry: If hearing loss is present — helps distinguish Meniere disease, labyrinthitis, acoustic neuroma, AICA stroke
14. ECG
An ECG should be obtained when there is any suspicion of a cardiac cause (presyncope, palpitations, exertional dizziness, irregular pulse, known cardiac history): [5][18]
- Arrhythmias: Atrial fibrillation/flutter, SVT, VT, sinus bradycardia < 40 bpm, sinus pauses > 3 seconds [19]
- Conduction disease: Second-degree Mobitz II or third-degree AV block, bundle branch block, alternating BBB [20]
- Channelopathies: Prolonged QTc (> 470 ms men, > 480 ms women), Brugada pattern (coved ST elevation V1-V2), delta wave (WPW) [20-21]
- Ischemia: ST changes, T-wave inversions
- Structural disease: LVH voltage criteria (HCM), epsilon waves/T-wave inversions V1-V3 (ARVC) [21]
15. Assessment
- Classify by TiTrATE first: triggered episodic, spontaneous episodic, or acute vestibular syndrome — this determines the differential and workup [2][5]
- Severity stratification: The key clinical question is peripheral vs. central. Most dizziness is benign, but posterior circulation stroke can present with isolated dizziness and mimic peripheral vertigo [5][22]
- Atypical presentations to recognize: Young patients with vertebral artery dissection, stroke without traditional risk factors, cerebellar stroke presenting as "vestibular neuritis" [5]
- Complications: Falls and injury (especially elderly), dehydration from vomiting, missed stroke with delayed presentation
16. Treatment Plan
BPPV
- Epley maneuver is first-line treatment — NNT of 3 for symptom resolution at 1 week; 88%–98% resolution at 1 month. May repeat 2–3 times in one session if nystagmus persists on repeat Dix-Hallpike [9][23]
- Meclizine is not effective for BPPV [9]
- Refer refractory cases to vestibular specialist [9]
Vestibular Neuritis
- Short-term vestibular suppressants (meclizine or low-dose benzodiazepine) for several days only [3]
- Consider short-term corticosteroids (e.g., methylprednisolone taper) — GRACE-3 suggests this as a treatment option [3]
- Early vestibular rehabilitation accelerates recovery [5]
Orthostatic Hypotension
Posterior Circulation Stroke
Cardiac Arrhythmia
Vestibular Migraine
17. Disposition
Admit: [3]
- Central HINTS exam or equivocal findings with vascular risk factors
- New focal neurologic deficits
- Inability to walk safely
- Hemodynamic instability or dangerous arrhythmia
- Severe intractable vomiting with dehydration
Observe
- Equivocal exam findings awaiting MRI
- Persistent symptoms after treatment with unclear etiology
Discharge: [3][3]
- Confirmed BPPV with successful Epley maneuver and ability to ambulate
- Vestibular neuritis with peripheral HINTS, no hearing loss, and ability to stand unaided — can be diagnosed without neuroimaging per GRACE-3 [3]
- Clear general medical cause identified and treated (e.g., dehydration, medication effect)
- Orthostatic hypotension with identified cause and stable vitals
Consult triggers: Neurology (suspected central cause, equivocal HINTS), ENT/neuro-otology (recurrent vertigo, hearing loss, refractory BPPV), Cardiology (arrhythmia, structural heart disease)
18. Follow Up / Return Precautions
- Follow-up timing: PCP within 1–3 days for vestibular neuritis; 1–2 weeks for BPPV (sooner if symptoms recur); specialist referral as indicated [3]
- Return immediately for: New weakness or numbness, speech difficulty, severe headache, vision changes, loss of consciousness, inability to walk, worsening or new symptoms
- Patient counseling:
- BPPV may recur (~50% recurrence within 5 years); patients can be taught self-treatment Epley maneuver [9]
- Vestibular neuritis: Expect gradual improvement over days to weeks; avoid prolonged bed rest; vestibular rehabilitation is beneficial [5]
- Avoid driving until symptoms resolve
- Fall precautions, especially in elderly
- Expected recovery: BPPV resolves rapidly with repositioning; vestibular neuritis typically improves over 1–3 weeks with central compensation; vestibular migraine requires long-term management
Would you like to dive deeper into any specific section — for example, a step-by-step guide to performing the HINTS exam, or management of a particular etiology like vestibular migraine or Meniere disease?
References
1. Head Impulse, Nystagmus, and Test of Skew Examination for Diagnosing Central Causes of Acute Vestibular Syndrome. — Gottlieb M, Peksa GD, Carlson JN. The Cochrane Database of Systematic Reviews. 2023.
2. ACR Appropriateness Criteria® Dizziness and Ataxia: 2023 Update. — Wang LL, Thompson TA, Shih RY, et al. Journal of the American College of Radiology : JACR. 2024.
3. Guidelines for Reasonable and Appropriate Care in the Emergency Department 3 (GRACE-3): Acute Dizziness and Vertigo in the Emergency Department. — Edlow JA, Carpenter C, Akhter M, et al. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine. 2023.
4. Dizziness in the Emergency Department and Risk of Stroke: A Systematic Review and Meta-Analysis. — Lin H, Zhu M, Zhang X, Tang Y. PloS One. 2026.
5. Dizziness: Evaluation and Management. — Rogers TS, Noel MA, Garcia B. American Family Physician. 2023.
6. Diagnostic Accuracy of the Physical Examination in Emergency Department Patients With Acute Vertigo or Dizziness: A Systematic Review and Meta-Analysis for GRACE-3. — Shah VP, Oliveira J E Silva L, Farah W, et al. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine. 2023.
7. Management and Rehabilitation of Post-Acute Mild Traumatic Brain Injury (mTBI) (2021). — Maj Thomas J. Bayuk DO, Amy O. Bowles MD, Lt Col Andrew W. Bursaw DO, et al Department of Veterans Affairs. 2021.
8. Orthostatic Hypotension: A Practical Approach. — Kim MJ, Farrell J. American Family Physician. 2022.
9. Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo. — Kerber KA, Carender W, Meurer WJ. The Journal of the American Medical Association. 2026.
10. Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review. — Colón-Emeric CS, McDermott CL, Lee DS, Berry SD. The Journal of the American Medical Association. 2024.
11. Development of a Clinical Risk Score to Risk Stratify for a Serious Cause of Vertigo in Patients Presenting to the Emergency Department. — Ohle R, Savage DW, Roy D, et al. Annals of Emergency Medicine. 2025.
12. Differentiating Central From Peripheral Causes of Acute Vertigo in an Emergency Setting With the HINTS, STANDING, and ABCD2 Tests: A Diagnostic Cohort Study. — Gerlier C, Hoarau M, Fels A, et al. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine. 2021.
13. Systematic Review and Meta-Analysis of the Diagnostic Accuracy of Spontaneous Nystagmus Patterns in Acute Vestibular Syndrome. — Wüthrich M, Wang Z, Martinez CM, et al. Frontiers in Neurology. 2023.
14. The Role of the HINTS Exam, TriAGe+ Score, and ABCD2 Score in Predicting Stroke in Acute Vertigo Patients in the ED. — Toplu ACO, Aslan IK, Akoglu EU, Ozturk TC. The American Journal of Emergency Medicine. 2025.
15. Using "HINTS Family" to Diagnose Stroke in the Acute Vestibular Syndrome: A Systematic Review and Meta-Analysis. — Xu W, Ling X, Chu H, et al. The American Journal of Emergency Medicine. 2025.
16. Diagnostic Accuracy of Neuroimaging in Emergency Department Patients With Acute Vertigo or Dizziness: A Systematic Review and Meta-Analysis for the Guidelines for Reasonable and Appropriate Care in the Emergency Department. — Shah VP, Oliveira J E Silva L, Farah W, et al. Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine. 2023.
17. Diagnostic Yield of MRI in Adult Patients With Dizziness or Vertigo at the Emergency Department: A Systematic Review and Meta-Analysis. — Jeong Y, Cho SJ, Lim H, et al. European Radiology. 2026.
18. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. — Shen WK, Sheldon RS, Benditt DG, et al. Journal of the American College of Cardiology. 2017.
19. New Concepts in the Assessment of Syncope. — Brignole M, Hamdan MH. Journal of the American College of Cardiology. 2012.
20. Syncope: Evaluation and Differential Diagnosis. — Bayard M, Gerayli F, Holt J. American Family Physician. 2023.
21. ECG Features That Suggest a Potentially Life-Threatening Arrhythmia as the Cause for Syncope. — Marine JE. Journal of Electrocardiology. 2013.
22. Pearls for the Emergency Clinician: Posterior Circulation Stroke. — Pelletier J, Koyfman A, Long B. The Journal of Emergency Medicine. 2023.
23. The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study. — Strupp M, Mandala M, Vinck AS, et al. JAMA Neurology. 2023.