Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
The initial investigations for a patient presenting with acute vertigo should involve a comprehensive assessment of their symptoms, medical history, and clinical findings NICE CKS.
Key considerations for initial assessment and investigation include:
Key considerations for initial assessment and investigation include:
- Identifying Red Flag Symptoms: It is crucial to look for features suggestive of a central cause of vertigo, which require urgent referral or admission NICE CKS. These include:
- Very sudden onset of vertigo (within seconds) that is not provoked by positional change and is persistent NICE CKS.
- Central neurological symptoms or signs, such as a new type of headache (especially occipital), gait disturbance, truncal ataxia, or vertical nystagmus NICE CKS.
- Acute deafness without other typical features of Meniere's disease NICE CKS.
- Isolated, persistent (>24 hours) vertigo of hyperacute (seconds) onset NICE CKS.
- Normal head impulse test NICE CKS.
- New onset unilateral deafness NICE CKS.
- Cranial nerve weakness or sensory loss, or limb weakness or sensory loss NICE CKS.
- Severe ataxia NICE CKS.
- Assessing for Stroke: Always consider the possibility of a stroke in people with new onset unilateral hearing loss and vertigo NICE CKS. For adults with sudden-onset dizziness and a focal neurological deficit (e.g., vertical or rotatory nystagmus, new-onset unsteadiness, new-onset deafness), check for and treat hypoglycaemia if the person has diabetes NICE NG127. If the person does not have diabetes, or if treating hypoglycaemia does not resolve symptoms, and benign paroxysmal positional vertigo (BPPV) or postural hypotension do not account for the presentation, refer immediately to exclude posterior circulation stroke NICE NG127.
- HINTS Test: For adults with sudden-onset acute vestibular syndrome (vertigo, nausea or vomiting, and gait unsteadiness), a HINTS (head-impulse–nystagmus–test-of-skew) test should be performed if a healthcare professional with training and experience in its use is available NICE NG127. A negative HINTS test makes a diagnosis of stroke very unlikely NICE NG127. If the HINTS test shows indications of stroke (a normal head impulse test, direction-changing nystagmus, or skew deviation), refer immediately for neuroimaging NICE NG127. If a trained professional for the HINTS test is not available, and BPPV or postural hypotension do not account for the presentation, refer immediately in line with local stroke pathways NICE NG127.
- Benign Paroxysmal Positional Vertigo (BPPV): For adults with transient rotational vertigo on head movement, offer the Hallpike manoeuvre to check for BPPV if a healthcare professional trained in its use is available NICE NG127. If BPPV is diagnosed, offer a canalith repositioning manoeuvre (such as the Epley manoeuvre) if a trained professional is available and the person does not have unstable cervical spine disease NICE NG127.
- Migrainous Vertigo: Be alert to the possibility of vestibular migraine in adults who have episodes of dizziness lasting between 5 minutes and 72 hours and a history of recurrent headache NICE NG127.
- Severity of Symptoms: Consider admission to hospital or urgent referral if the person has severe nausea and vomiting and is unable to tolerate oral fluids or symptomatic drug treatment NICE CKS.