Sudden severe headache unlike any previous headache
Worst headache of life
Different from usual migraine
Unable to walk or severe loss of balance
Different from initial dizziness
New or rapidly worsening
Loss of consciousness or near-fainting
Especially with chest pain or palpitations
Symptoms worsening rather than improving after 24 to 48 hours
No improvement despite following treatment plan
New symptoms added to original complaint
Sudden hearing loss
In one or both ears
Especially with ongoing dizziness
Follow-up plan
BPPV
Family doctor or clinic within 1 to 2 weeks
Return sooner if symptoms recur or worsen
Vestibular neuritis
Family doctor within 1 to 3 days
Vestibular rehabilitation referral if symptoms persist beyond 1 week
Unclear cause requiring further investigation
Specialist appointment as arranged
MRI or further testing as ordered
References
Guidelines and key sources
Primary clinical practice guidelines
GRACE-3: Edlow JA et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department 3: Acute Dizziness and Vertigo in the Emergency Department. Academic Emergency Medicine 2023
TiTrATE framework
HINTS exam guidance
ACR Appropriateness Criteria: Wang LL et al. ACR Appropriateness Criteria Dizziness and Ataxia: 2023 Update. Journal of the American College of Radiology 2024
Imaging appropriateness for dizziness presentations
AAFP Rogers TS et al. Dizziness: Evaluation and Management. American Family Physician 2023
Primary care-based algorithm including TiTrATE
HINTS exam evidence
Cochrane Review: Gottlieb M, Peksa GD, Carlson JN. Head Impulse, Nystagmus, and Test of Skew Examination for Diagnosing Central Causes of Acute Vestibular Syndrome. Cochrane Database of Systematic Reviews 2023
Sensitivity 92% to 100%, specificity 81% to 86%
HINTS family meta-analysis: Xu W et al. Using HINTS Family to Diagnose Stroke in the Acute Vestibular Syndrome. American Journal of Emergency Medicine 2025
Physical examination accuracy: Shah VP et al. Diagnostic Accuracy of the Physical Examination in ED Patients With Acute Vertigo or Dizziness. Academic Emergency Medicine 2023
BPPV evidence
JAMA review: Kerber KA, Carender W, Meurer WJ. Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo. JAMA 2026
Semont-Plus vs Epley: Strupp M et al. JAMA Neurology 2023
Randomized clinical study showing equivalent efficacy
Neuroimaging evidence
Neuroimaging accuracy: Shah VP et al. Diagnostic Accuracy of Neuroimaging in ED Patients With Acute Vertigo or Dizziness. Academic Emergency Medicine 2023
MRI diagnostic yield meta-analysis: Jeong Y et al. European Radiology 2026
Overall diagnostic yield approximately 13%; isolated dizziness approximately 4% to 6%
CT sensitivity for posterior fossa stroke approximately 16% to 28%
Stroke risk and prediction tools
Sudbury Vertigo Risk Score: Ohle R et al. Development of a Clinical Risk Score to Risk Stratify for a Serious Cause of Vertigo. Annals of Emergency Medicine 2025
C-statistic 0.96
Stroke risk meta-analysis: Lin H et al. Dizziness in the Emergency Department and Risk of Stroke: Systematic Review and Meta-Analysis. PloS One 2026
Posterior circulation stroke pearls: Pelletier J, Koyfman A, Long B. Pearls for the Emergency Clinician: Posterior Circulation Stroke. Journal of Emergency Medicine 2023
Geriatric and falls evidence
JAMA falls review: Colon-Emeric CS et al. Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults. JAMA 2024
Orthostatic hypotension: Kim MJ, Farrell J. Orthostatic Hypotension: A Practical Approach. American Family Physician 2022
Coding references
ICD-10 H81.1 BPPV
H81.2 vestibular neuritis
H81.0 Meniere disease
ICD-10 I63 cerebral infarction (posterior circulation subtypes I63.0 to I63.9)
G45.0 vertebrobasilar artery syndrome TIA
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