When should I consider referring a patient with vertigo for specialist assessment or imaging?

Consider referring a patient with vertigo for specialist assessment or imaging if any of the following are present:

• Severe nausea and vomiting preventing oral fluid intake or symptomatic treatment, requiring hospital admission or urgent specialist referral ¹.
• Very sudden onset of vertigo (within seconds), persistent and not provoked by positional change ¹.
• Central neurological symptoms or signs such as new headache (especially occipital), gait disturbance, truncal ataxia, vertical nystagmus, cranial nerve weakness, sensory loss, or limb weakness ¹,⁴.
• New onset unilateral hearing loss with vertigo, as this may indicate stroke and requires urgent referral ¹.
• Isolated persistent vertigo lasting more than 24 hours with hyperacute onset, normal head impulse test, new headache, or other neurological signs ¹,⁴.
• Failure to respond to appropriate treatment for benign paroxysmal positional vertigo (BPPV) after two canalith repositioning procedures or presence of atypical symptoms/signs such as hearing loss, tinnitus, or middle ear infection signs ³.
• Suspected migrainous vertigo requiring confirmation ¹.
• Sudden-onset acute vestibular syndrome with focal neurological deficit or if HINTS test indicates stroke, urgent neuroimaging is required ⁴.

While awaiting specialist assessment, consider short-term symptomatic drug treatment but do not delay referral ¹,⁴.