Vertigo in ED

Vertigo is not always labyrinthitis!! There are some potentially serious conditions to think about. Your main question should be is it peripheral [good] or central [bad]?

IndicatorPeripheral Central
IntensityMaximum initial Mild
Vertical Nystagmus NoYes
Affect of Movement Significant Mild-None
Other NeurologyAbsentPresent
WalkingAbleFalls, V. unstable
HINTS ExamAll PeripheralAny Central

Think about the HINTS exam, its particularly good at identifying posterior strokes (however the patient needs to feel dizzy at reg time of the test)


Vest. NeuritisDaysNoPeripheral
Perilymphatic fistulasecondsYesPeripheral
Acoustic neuromaMonthsYesPeripheral
Migraine (Vest.)HoursNoCentral

HINTS Exam – video link

Head Impulse test

  • Rapid passive rotation of head while patient fixes on your nose
  • Fixes on nose (central/normal)
  • Eyes Correct (periph)


  • Bilat/Vertical (central)
  • Horiz. Unilat (periph)

Test of Skew

  • Repeated cover test of eyes while fixed on nose.
  • Eyes move (central)
  • Eyes steady (periph)


  • Any central features would indicate a central vertigo
  • Caution – Only valid if patient dizzy at time. As head impulse test will be normal/central if not dizzy.
  • Accuracy – More sensitive than MRI. Sensitivity 96-100% Specificity 85-98%


  • Prochloperazine PO 5mg TDS
  • Prochloperazine injection 12.5 mg im
  • Betahistine 16mg tds (most effective in Meniere’s)
  • Habituation
    • Identified dizziness-provoking movements
    • Repeat them: five times in a row and twice a day
    • Helps to achieve vestibular compensation.
  • Follow-Up
    • Peripheral – GP/ENT clinic
    • Central – Admission +/- imaging (Discuss with admitting team/radiology as MRI/CTA may be more appropriate than plan CT)


Vertigo – Guide to the big 3

1. Any features that mandate imaging?

  • Neurology deficit
  • Significant headache
  • Neck pain
  • Unable to stand or walk
  • Spontaneous vertical nystagmus (i.e. not while doing dix-hallpike)

2. History

  • Short episodes <2 min brought on by movement, no spontaneous nystagmus (i.e. only on move)
    • BPPV > Dix-Hallpike
  • Dizzy for Hours
    • Vestibular neuritis vs central > HINTSplus exam (you can only use HINTS if patient is dizzy and has nystagmus)

Posterior canal BPPV – Dix-Hallpike and Epley manoeuvre

Horizontal canal BPPV sounds similar to posterior canal (D-H+eply) but tends severe when moves head when upright – tests and how to treat different

Vestibular migraine

One to think about if patient presents without nystagmus  – patient should state:

  • Recurrent (at least 5 episodes)
  • Lasts unto 72hrs
  • Has a temporal relationship to migraine symptoms (this may be aura symptoms not headache) at least 50% of the time

Apparently 2.5% population get this, most un/miss-diagnosed, metacloprimide can help


DVLA – sudden onset dizziness

search: dizzy, dizziness,

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