Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Flow Diagram for Management of Vertigo in Primary Care (NICE CKS)
- Step 1: Initial Assessment
Assess symptoms, medical history, and clinical findings in adults (≥18 years) presenting with vertigo NICE CKS. - Step 2: Identify Red Flags for Central Causes
Check for hyperacute onset (max intensity in minutes), neurological signs (new headache, gait disturbance, truncal ataxia, vertical or torsional nystagmus), acute unilateral deafness, or new headache NICE CKS. - Step 3: Urgent Referral or Admission
If any red flags present, refer immediately for specialist assessment or admit to hospital to exclude brainstem stroke or other central causes NICE CKS,NICE NG127. - Step 4: Consider Peripheral Vertigo Causes
If peripheral vertigo suspected (e.g., benign paroxysmal positional vertigo, Meniere's disease, vestibular neuronitis), manage accordingly or refer to balance specialist if diagnosis unclear NICE CKS,NICE CKS. - Step 5: Symptomatic Treatment
Offer short-term symptomatic drug treatment (up to 1 week) with prochlorperazine, cinnarizine, cyclizine, or promethazine teoclate for nausea, vomiting, and vertigo NICE CKS. Avoid benzodiazepines due to lack of evidence and dependence risk NICE CKS. - Step 6: Severe Symptoms
If severe nausea/vomiting prevents oral intake or drug treatment, consider hospital admission or urgent referral NICE CKS. - Step 7: Specialist Referral for Undetermined Cause
If vertigo cause remains unclear after assessment, refer to an ear, nose, and throat specialist, audiovestibular physician, neurologist, or geriatrician with balance expertise, urgency based on clinical judgement NICE CKS. - Step 8: Vestibular Rehabilitation
For vestibular neuronitis or unilateral vestibular hypofunction, consider vestibular rehabilitation to improve symptoms and function NICE CKS. - Step 9: Monitor and Seek Specialist Advice if Symptoms Deteriorate
If symptoms worsen or new neurological signs develop, seek specialist advice promptly NICE CKS.