When should I consider referring a patient with vestibular migraine to a specialist for further evaluation?

Consider referring a patient with vestibular migraine to a specialist for further evaluation if:

• There is diagnostic uncertainty and confirmation of vestibular migraine is needed, especially if symptoms are severe or atypical.
• The patient has recurrent episodes of dizziness lasting between 5 minutes and 72 hours with a history of recurrent headache, raising suspicion of vestibular migraine that requires specialist assessment.
• Symptoms deteriorate or do not respond to initial management in primary care.
• There are associated neurological symptoms or signs that suggest a central cause of vertigo, warranting urgent specialist evaluation.
• The patient is unable to tolerate oral fluids or symptomatic drug treatment due to severe nausea and vomiting.

Referral should be made to an appropriate balance specialist such as a neurologist or audiovestibular physician depending on local service provision, with urgency guided by symptom severity and clinical judgement.

While awaiting specialist assessment, consider offering short-term symptomatic drug treatment but do not delay referral for this.

This approach aligns with NICE guidance on suspected neurological conditions and vertigo management in adults.

NICE CKS,NICE NG127