Vertigo Evaluation¶
DIAGNOSIS: Vertigo (Dizziness and Giddiness) ICD-10: R42 (Dizziness and giddiness) ADDITIONAL ICD-10: H81.10 (BPPV, unspecified ear), H81.23 (Vestibular neuritis, bilateral), H81.09 (Meniere's disease, unspecified ear), H83.2X9 (Labyrinthitis, unspecified ear) SCOPE: Evaluation of acute and chronic vertigo including differentiation of peripheral vs central causes. Covers BPPV, vestibular neuritis, labyrinthitis, and Meniere's disease workup. Includes red flag identification for posterior circulation stroke. Excludes presyncope, orthostatic hypotension, and cardiac causes of dizziness.
STATUS: Draft - Pending Review
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
SECTION A: ACTION ITEMS¶
1. LABORATORY WORKUP¶
1A. Essential/Core Labs¶
| Test | Rationale | Target Finding | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|
| Glucose (fingerstick or serum) | Hypoglycemia can cause dizziness/lightheadedness mimicking vertigo | Normal (70-100 mg/dL) | STAT | STAT | ROUTINE | STAT |
| CBC | Rule out anemia (causes lightheadedness), infection (labyrinthitis) | Normal Hgb, WBC | STAT | ROUTINE | ROUTINE | STAT |
| BMP | Electrolyte disturbance can cause dizziness; assess renal function | Normal Na, K, glucose, creatinine | STAT | ROUTINE | ROUTINE | STAT |
| TSH | Thyroid dysfunction can cause vestibular symptoms | Normal (0.4-4.0 mIU/L) | - | ROUTINE | ROUTINE | - |
1B. Extended Workup (Second-line)¶
| Test | Rationale | Target Finding | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|
| HbA1c | Screen for diabetes if neuropathy suspected contributing to imbalance | <5.7% (normal); <7% (controlled DM) | - | ROUTINE | ROUTINE | - |
| Vitamin B12 | Deficiency causes peripheral neuropathy affecting balance | >300 pg/mL | - | ROUTINE | ROUTINE | - |
| RPR/VDRL | Neurosyphilis can cause vestibular symptoms | Nonreactive | - | EXT | ROUTINE | - |
| ESR, CRP | Elevated in vasculitis, autoimmune inner ear disease | Normal ESR (<20 mm/hr), CRP (<3 mg/L) | - | ROUTINE | ROUTINE | - |
| Lipid panel | Vascular risk assessment if central cause suspected | LDL <100 mg/dL; HDL >40 mg/dL | - | ROUTINE | ROUTINE | - |
1C. Rare/Specialized (Refractory or Atypical)¶
| Test | Rationale | Target Finding | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|
| ANA, anti-dsDNA | Autoimmune inner ear disease (AIED) suspected | Negative | - | EXT | EXT | - |
| Anti-HSP70 antibody | Specific marker for autoimmune inner ear disease | Negative | - | - | EXT | - |
| Lyme serology | Endemic area with vestibular and facial nerve involvement | Negative | - | EXT | EXT | - |
| FTA-ABS | Confirmatory test if RPR positive; otosyphilis | Nonreactive | - | EXT | EXT | - |
| Genetic testing (COCH, MYO7A) | Familial vestibular disorders, Usher syndrome | No pathogenic variant | - | - | EXT | - |
2. DIAGNOSTIC IMAGING & STUDIES¶
2A. Essential/First-line¶
| Study | Timing | Target Finding | Contraindications | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| CT Head non-contrast | Acute vertigo with concern for hemorrhage or when MRI unavailable | No hemorrhage, mass, or acute stroke | Pregnancy (relative) | STAT | - | - | STAT |
| MRI Brain with DWI | Central vertigo suspected; abnormal HINTS exam; risk factors for stroke | No acute infarct; normal brainstem/cerebellum | MRI-incompatible devices, severe claustrophobia | URGENT | URGENT | ROUTINE | URGENT |
| MRA Head (Circle of Willis) | Posterior circulation stroke suspected; vertebral/basilar stenosis | Patent posterior circulation; no stenosis | MRI contraindications | URGENT | URGENT | ROUTINE | - |
2B. Extended¶
| Study | Timing | Target Finding | Contraindications | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| MRI Internal Auditory Canals (IAC) with contrast | Unilateral hearing loss with vertigo; acoustic neuroma suspected | No vestibular schwannoma or CPA lesion | Gadolinium allergy, severe CKD | - | ROUTINE | ROUTINE | - |
| CTA Head/Neck | Vertebral dissection suspected; if MRA unavailable | No dissection; patent vertebral arteries | Contrast allergy, CKD | STAT | URGENT | - | STAT |
| Audiometry | Sensorineural hearing loss; Meniere's suspected | Symmetric hearing; low-frequency loss in Meniere's | None | - | ROUTINE | ROUTINE | - |
| Videonystagmography (VNG) | Quantify vestibular function; localize peripheral lesion | Identify unilateral weakness; canal paresis | Acute severe vertigo (defer until improved) | - | EXT | ROUTINE | - |
| Electrocochleography (ECoG) | Meniere's disease confirmation | Elevated SP/AP ratio >0.4 | Recent ear surgery | - | - | EXT | - |
2C. Rare/Specialized¶
| Study | Timing | Target Finding | Contraindications | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| Vestibular evoked myogenic potentials (VEMP) | Superior canal dehiscence; saccular function | Abnormal thresholds or amplitudes | Hearing aids (remove first) | - | - | EXT | - |
| High-resolution CT temporal bones | Superior canal dehiscence; cholesteatoma | Identify bony abnormalities | Pregnancy | - | EXT | EXT | - |
| Rotary chair testing | Bilateral vestibular loss; compensation assessment | Assess VOR gain and phase | Severe vertigo (defer) | - | - | EXT | - |
| Video head impulse test (vHIT) | Quantify VOR for each semicircular canal | Normal gain >0.8; refixation saccades | None | - | EXT | ROUTINE | - |
3. TREATMENT¶
3A. Acute/Emergent¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Meclizine | PO | Acute vertigo; vestibular suppressant | 25 mg PO; 25 mg TID; 50 mg TID :: PO :: :: 25-50 mg PO q6-8h PRN vertigo; max 150 mg/day | Glaucoma; urinary retention; elderly (fall risk) | Sedation, anticholinergic effects | STAT | STAT | ROUTINE | - |
| Dimenhydrinate (Dramamine) | PO/IV | Acute vertigo with significant nausea | 50 mg PO; 50 mg IV :: PO/IV :: :: 50 mg PO q6h or 50 mg IV q6h PRN; max 400 mg/day | Same as meclizine; IV form may cause hypotension | Sedation, BP if IV | STAT | STAT | ROUTINE | - |
| Ondansetron | IV/PO | Nausea/vomiting with acute vertigo | 4 mg IV; 8 mg PO; 4 mg ODT :: IV/PO :: :: 4 mg IV or 4-8 mg PO/ODT q8h PRN | QT prolongation; severe hepatic impairment | QTc if multiple doses or risk factors | STAT | STAT | ROUTINE | - |
| Promethazine | IV/IM/PO | Severe nausea with acute vertigo | 12.5 mg IV; 25 mg IV; 25 mg PO :: IV/IM/PO :: :: 12.5-25 mg IV/IM/PO q4-6h PRN; max 100 mg/day | Respiratory depression; Parkinson's; children <2 years | Sedation, respiratory status, dystonia | URGENT | URGENT | - | - |
| Lorazepam | IV/PO | Severe acute vertigo refractory to antihistamines | 0.5 mg IV; 1 mg IV; 0.5 mg PO; 1 mg PO :: IV/PO :: :: 0.5-1 mg IV/PO q8h PRN severe vertigo; short-term use only | Respiratory depression; severe hepatic impairment; angle-closure glaucoma | Sedation, respiratory status | URGENT | URGENT | - | - |
| Diazepam | PO | Vestibular suppressant; more sedating | 2 mg PO; 5 mg PO :: PO :: :: 2-5 mg PO q8-12h PRN vertigo; limit to 3-5 days | Same as lorazepam | Sedation, respiratory status | URGENT | URGENT | ROUTINE | - |
| IV Normal Saline | IV | Dehydration from vomiting | 1000 mL IV bolus; 125 mL/hr IV :: IV :: :: 1-2 L bolus then maintenance as needed | Heart failure; volume overload | Intake/output, signs of overload | STAT | STAT | - | STAT |
3B. Symptomatic Treatments¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Epley maneuver (canalith repositioning) | Physical | BPPV - posterior canal (most common) | Perform once; may repeat x2 same session :: Physical :: :: Modified Epley: 5 positions held 30-60 sec each; may repeat if persistent nystagmus | Severe cervical spine disease; carotid stenosis (relative) | Nystagmus resolution; post-maneuver restrictions controversial | STAT | STAT | ROUTINE | - |
| Semont maneuver | Physical | BPPV - alternative to Epley | Perform once :: Physical :: :: Side-lying liberatory maneuver; faster but more uncomfortable | Same as Epley | Nystagmus resolution | URGENT | URGENT | ROUTINE | - |
| Brandt-Daroff exercises | Physical | BPPV - home exercise; residual symptoms | Twice daily home exercise :: Physical :: :: Sit-to-side x5 each side, 30 sec holds, BID for 2 weeks | Severe nausea (defer until improved) | Symptom diary | - | ROUTINE | ROUTINE | - |
| Lempert maneuver (BBQ roll) | Physical | BPPV - horizontal canal variant | Perform once; may repeat :: Physical :: :: Serial 90-degree rolls toward unaffected ear (360 total) | Cervical spine disease | Nystagmus resolution | URGENT | URGENT | ROUTINE | - |
| Prochlorperazine | IV/PO | Vertigo with significant nausea | 10 mg IV; 10 mg PO :: IV/PO :: :: 5-10 mg IV/PO q6-8h PRN; max 40 mg/day | Parkinson's; QT prolongation; tardive dyskinesia history | Akathisia, dystonia, QTc | URGENT | URGENT | ROUTINE | - |
| Scopolamine patch | Transdermal | Motion sickness; prolonged vertigo episodes | 1 patch q72h :: Transdermal :: :: Apply 1 patch behind ear; replace q72h; remove if symptoms resolve | Glaucoma; urinary retention; elderly | Anticholinergic effects, dry mouth | - | ROUTINE | ROUTINE | - |
3C. Second-line/Refractory¶
| Treatment | Route | Indication | Dosing | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|
| Methylprednisolone | PO | Vestibular neuritis - may improve recovery | 100 mg daily x 3 days; 80 mg daily; 60 mg daily; 40 mg daily; 20 mg daily; 10 mg daily :: PO :: :: 100 mg daily x3 days, then taper over 3 weeks (total 22-day course) | Active infection; uncontrolled diabetes; psychosis | Glucose, BP, mood | - | URGENT | ROUTINE | - |
| Prednisone | PO | Vestibular neuritis - alternative steroid | 60 mg daily; 40 mg daily; 20 mg daily :: PO :: :: 1 mg/kg/day (max 60 mg) x 5 days, taper over 2 weeks | Same as methylprednisolone | Glucose, BP, mood | - | URGENT | ROUTINE | - |
| Valacyclovir | PO | Vestibular neuritis - if viral etiology suspected | 1000 mg TID x 7 days :: PO :: :: 1000 mg PO TID x 7 days; most effective if started within 72 hrs | Renal impairment (dose adjust) | Renal function | - | ROUTINE | ROUTINE | - |
| Betahistine | PO | Meniere's disease - vestibular blood flow | 16 mg TID; 24 mg TID :: PO :: :: 8-16 mg PO TID; titrate to 24 mg TID if needed; not FDA approved in US | Pheochromocytoma; active peptic ulcer | GI upset, headache | - | ROUTINE | ROUTINE | - |
| Hydrochlorothiazide | PO | Meniere's disease - reduce endolymphatic pressure | 25 mg daily; 50 mg daily :: PO :: :: 12.5-50 mg PO daily | Sulfa allergy; hypokalemia; severe renal impairment | K+, Na+, creatinine, glucose | - | - | ROUTINE | - |
| Triamterene/HCTZ | PO | Meniere's disease - potassium-sparing diuretic | 37.5/25 mg daily :: PO :: :: 37.5/25 mg PO daily | Hyperkalemia; severe renal impairment | K+, creatinine | - | - | ROUTINE | - |
| Intratympanic dexamethasone | IT | Refractory Meniere's disease | 4 mg/mL IT injection :: Intratympanic :: :: 0.4-0.8 mL of 4-24 mg/mL solution injected through TM; repeat x3-4 over 2 weeks | Active ear infection; perforated TM | Hearing, vertigo control | - | - | EXT | - |
| Intratympanic gentamicin | IT | Refractory Meniere's disease - ablative | 40 mg/mL IT injection :: Intratympanic :: :: Chemical labyrinthectomy; 0.5 mL of 40 mg/mL; may repeat in 4 weeks | Only hearing ear; bilateral disease | Hearing loss (expected), vertigo control | - | - | EXT | - |
3D. Disease-Modifying or Chronic Therapies¶
| Treatment | Route | Indication | Dosing | Pre-Treatment Requirements | Contraindications | Monitoring | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|---|---|---|
| Vestibular rehabilitation therapy | Physical | Vestibular hypofunction; chronic imbalance | 1-2x weekly sessions :: Physical :: :: 6-12 week program with home exercises; gaze stabilization, balance training, habituation | Audiometry, VNG to define deficit | Acute vertigo (defer) | Fall risk, symptom diary, DHI scores | - | ROUTINE | ROUTINE | - |
| Low-sodium diet | Dietary | Meniere's disease - reduce endolymph | <1500-2000 mg Na/day :: Dietary :: :: Strict sodium restriction; avoid processed foods, add no salt | Dietitian consultation | Hypotension if on diuretics | BP, symptoms, dietary compliance | - | ROUTINE | ROUTINE | - |
| Caffeine/alcohol avoidance | Lifestyle | Meniere's disease; vestibular migraine | Eliminate or minimize :: Lifestyle :: :: Avoid caffeine and alcohol which may trigger episodes | None | None | Symptom diary | - | ROUTINE | ROUTINE | - |
| Migraine preventive therapy | PO | Vestibular migraine confirmed | Per migraine protocol :: PO :: :: See Migraine plan for preventive options (topiramate, propranolol, amitriptyline) | HIS/Barany criteria for vestibular migraine | Per specific medication | Per specific medication | - | - | ROUTINE | - |
4. OTHER RECOMMENDATIONS¶
4A. Referrals & Consults¶
| Recommendation | ED | HOSP | OPD | ICU |
|---|---|---|---|---|
| Neurology consultation for central vertigo evaluation when HINTS exam suggests central lesion or stroke suspected | STAT | STAT | ROUTINE | STAT |
| ENT/Otology referral for refractory BPPV, Meniere's disease management, or hearing loss evaluation | - | ROUTINE | ROUTINE | - |
| Vestibular physical therapy for vestibular rehabilitation and balance retraining after acute vertigo resolves | - | ROUTINE | ROUTINE | - |
| Audiology for formal hearing assessment and vestibular function testing (VNG, VEMP) | - | ROUTINE | ROUTINE | - |
| Neuro-ophthalmology if ocular motor abnormalities persist or skew deviation concerning for brainstem lesion | - | ROUTINE | ROUTINE | - |
| Stroke neurology for urgent evaluation if HINTS-plus exam suggests posterior circulation stroke | STAT | STAT | - | STAT |
| Cardiology if presyncope suspected or arrhythmia contributing to dizziness | URGENT | ROUTINE | ROUTINE | - |
4B. Patient Instructions¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Return immediately if vertigo associated with new headache, diplopia, dysarthria, dysphagia, or weakness (signs of stroke) | STAT | - | ROUTINE |
| Return immediately if sudden hearing loss occurs which requires urgent treatment within 72 hours | STAT | - | ROUTINE |
| Avoid driving, operating machinery, or working at heights until vertigo resolves completely due to fall and accident risk | URGENT | ROUTINE | ROUTINE |
| Use assistive devices (cane, walker) if balance impaired to prevent falls | URGENT | ROUTINE | ROUTINE |
| Perform Brandt-Daroff exercises twice daily as instructed if diagnosed with BPPV | - | ROUTINE | ROUTINE |
| Keep head elevated 30-45 degrees when sleeping for 24-48 hours after Epley maneuver (controversial but commonly recommended) | URGENT | ROUTINE | ROUTINE |
| Avoid sudden head movements and rapid position changes which may trigger vertigo | URGENT | ROUTINE | ROUTINE |
| Maintain hydration and avoid skipping meals as dehydration and hypoglycemia can worsen symptoms | ROUTINE | ROUTINE | ROUTINE |
4C. Lifestyle & Prevention¶
| Recommendation | ED | HOSP | OPD |
|---|---|---|---|
| Sodium restriction (<2000 mg/day) if Meniere's disease diagnosed to reduce attack frequency | - | ROUTINE | ROUTINE |
| Caffeine reduction or elimination as caffeine can exacerbate vestibular symptoms | - | ROUTINE | ROUTINE |
| Alcohol avoidance as alcohol directly affects vestibular function and can trigger episodes | - | ROUTINE | ROUTINE |
| Stress management through relaxation techniques as stress can trigger vestibular migraine and Meniere's attacks | - | ROUTINE | ROUTINE |
| Regular sleep schedule as sleep deprivation can worsen vestibular symptoms | - | ROUTINE | ROUTINE |
| Fall prevention measures including removing throw rugs, installing grab bars, adequate lighting at home | - | ROUTINE | ROUTINE |
| Smoking cessation to reduce vascular risk factors that contribute to central vertigo | - | ROUTINE | ROUTINE |
SECTION B: REFERENCE¶
5. DIFFERENTIAL DIAGNOSIS¶
| Alternative Diagnosis | Key Distinguishing Features | Tests to Differentiate |
|---|---|---|
| BPPV (posterior canal) | Brief episodes (<1 min) triggered by position change; positive Dix-Hallpike with upbeat-torsional nystagmus | Dix-Hallpike maneuver; resolves with Epley |
| BPPV (horizontal canal) | Horizontal nystagmus with supine roll test; direction-changing or direction-fixed | Supine roll test; treat with BBQ roll maneuver |
| Vestibular neuritis | Acute severe vertigo lasting days; unidirectional horizontal nystagmus; normal hearing | HINTS exam (peripheral pattern); MRI to rule out stroke |
| Labyrinthitis | Same as vestibular neuritis PLUS hearing loss; may follow URI | Audiometry shows sensorineural loss; HINTS peripheral |
| Meniere's disease | Recurrent episodes (20 min - 12 hr) with hearing loss, tinnitus, aural fullness | Audiometry (low-frequency loss); ECoG; MRI IAC |
| Vestibular migraine | Vertigo with migraine features; variable duration (5 min - 72 hr); motion sensitivity | HIS/Barany criteria; diagnosis of exclusion; MRI normal |
| Posterior circulation stroke | Acute vertigo + neurological signs; HINTS central pattern; vascular risk factors | MRI DWI (may be negative early); HINTS exam |
| Cerebellar hemorrhage/infarct | Severe imbalance; unable to walk; may have headache, vomiting | CT head (hemorrhage); MRI DWI (infarct) |
| Multiple sclerosis | Vertigo with other demyelinating symptoms; younger patient | MRI brain/spine with contrast; CSF oligoclonal bands |
| Acoustic neuroma | Progressive unilateral hearing loss, tinnitus; vertigo less prominent | MRI IAC with gadolinium |
| Perilymphatic fistula | Vertigo/hearing loss after trauma, straining, or barotrauma | History; may need surgical exploration |
| Superior canal dehiscence | Vertigo triggered by loud sounds (Tullio) or pressure; autophony | High-resolution CT temporal bone; VEMP |
| Central positional vertigo | Down-beating nystagmus with Dix-Hallpike; doesn't fatigue | MRI cerebellum; Dix-Hallpike pattern |
| Drug-induced vestibulotoxicity | Bilateral vestibular loss; aminoglycosides, loop diuretics, chemotherapy | History; bilateral caloric weakness on VNG |
| Presyncope (cardiac) | Near-fainting rather than spinning; palpitations; exertional | ECG, Holter, echocardiogram; orthostatic vitals |
| Orthostatic hypotension | Dizziness on standing; BP drop >20/10 mmHg | Orthostatic vital signs |
| Anxiety/panic disorder | Chronic dizziness; associated anxiety; no objective vestibular findings | Normal vestibular testing; psychiatric evaluation |
6. MONITORING PARAMETERS¶
| Parameter | Frequency | Target/Threshold | Action if Abnormal | ED | HOSP | OPD | ICU |
|---|---|---|---|---|---|---|---|
| HINTS exam (Head Impulse, Nystagmus, Test of Skew) | Initial presentation | Peripheral pattern (HI abnormal, Nystagmus unidirectional, Skew absent) | Central pattern requires urgent MRI and neurology consult | STAT | STAT | - | STAT |
| Nystagmus characteristics | Serial exam in ED | Unidirectional; suppresses with fixation | Direction-changing, vertical, or non-suppressing suggests central | STAT | STAT | ROUTINE | STAT |
| Gait and balance assessment | Each encounter | Able to ambulate safely | Unable to walk suggests central lesion or severe peripheral | STAT | ROUTINE | ROUTINE | - |
| Hearing assessment (bedside) | Initial and follow-up | Symmetric hearing | Asymmetric loss requires audiometry and MRI IAC | URGENT | ROUTINE | ROUTINE | - |
| Symptom severity (VAS or DHI) | Each visit | Improving over time | Persistent or worsening requires imaging, reassessment | - | ROUTINE | ROUTINE | - |
| Dix-Hallpike test | If BPPV suspected; follow-up | Negative (resolved) | Positive requires repositioning; recurrence common | STAT | ROUTINE | ROUTINE | - |
| Fall risk assessment | Each encounter | Low risk | High risk requires PT, home safety evaluation, assistive devices | URGENT | ROUTINE | ROUTINE | - |
| Vestibular function (VNG/VEMP) | After acute phase; follow-up | Compensation occurring | Persistent deficit requires vestibular rehabilitation | - | - | ROUTINE | - |
7. DISPOSITION CRITERIA¶
| Disposition | Criteria |
|---|---|
| Discharge home | Peripheral vertigo confirmed (HINTS peripheral); symptoms controlled; able to ambulate safely; able to tolerate PO; follow-up arranged; no red flags |
| Observation | Severe symptoms requiring IV fluids/medications; unable to ambulate safely; awaiting MRI to rule out central cause |
| Admit to floor | Central vertigo confirmed requiring workup; stroke suspected but stable; severe dehydration; unable to tolerate PO for >24 hours |
| Admit to ICU | Cerebellar stroke with risk of herniation; cerebellar hemorrhage; posterior circulation stroke with fluctuating symptoms |
| Transfer to higher level | Central vertigo suspected and MRI/neurology not available; cerebellar stroke requiring neurosurgical evaluation |
| Outpatient follow-up | Within 1-2 weeks for new vertigo; sooner if symptoms persist; ENT referral for Meniere's or hearing loss |
8. EVIDENCE & REFERENCES¶
| Recommendation | Evidence Level | Source |
|---|---|---|
| HINTS exam superior to early MRI for detecting stroke | Class II, Level B | Kattah et al. Stroke 2009 |
| Epley maneuver effective for posterior canal BPPV | Class I, Level A | Hilton et al. Cochrane Database Syst Rev 2014 |
| Corticosteroids improve vestibular neuritis recovery | Class I, Level B | Strupp et al. NEJM 2004 |
| Vestibular rehabilitation effective for chronic vestibular hypofunction | Class I, Level A | McDonnell & Hillier Cochrane 2015 |
| HINTS-plus (HINTS + hearing) increases stroke detection | Class II, Level B | Newman-Toker et al. Stroke 2013 |
| Betahistine for Meniere's disease symptoms | Class II, Level B | James & Burton Cochrane 2001 |
| Intratympanic gentamicin for refractory Meniere's | Class II, Level B | Pullens & van Benthem Cochrane 2011 |
| Meclizine comparable to diazepam for acute vertigo | Class II, Level B | McClure & Willett Arch Otolaryngol 1980 |
| Low sodium diet for Meniere's disease management | Class III, Level C | Luxford et al. Otolaryngol Head Neck Surg 2013 |
| Diagnostic criteria for vestibular migraine | Consensus | Lempert et al. Barany Society/IHS 2012 |
| Video head impulse test for vestibular function | Class II, Level B | MacDougall et al. Neurology 2009 |
| Central vs peripheral vertigo differentiation | Consensus | Baloh & Honrubia. Clinical Neurophysiology of Vestibular System 2011 |
CHANGE LOG¶
v1.0 (January 27, 2026) - Initial template creation - Comprehensive coverage of peripheral and central vertigo evaluation - HINTS exam protocol for ED differentiation - BPPV diagnosis and canalith repositioning maneuvers - Vestibular neuritis, labyrinthitis, and Meniere's disease workup - Structured dosing format for order sentence generation - PubMed-verified citations
APPENDIX A: HINTS Exam Protocol¶
HINTS Examination for Acute Vestibular Syndrome¶
The HINTS exam differentiates peripheral from central causes of acute vertigo with higher sensitivity than early MRI for posterior circulation stroke.
When to Use: Acute continuous vertigo with nystagmus (Acute Vestibular Syndrome)
H - Head Impulse Test (HIT) 1. Patient fixes gaze on examiner's nose 2. Rapidly turn head 10-20 degrees to each side 3. Peripheral: Catch-up saccade when turning toward affected ear (abnormal/positive) 4. Central: No catch-up saccade (normal/negative) - concerning for stroke
I - Nystagmus 1. Observe spontaneous nystagmus 2. Note direction and whether it changes with gaze direction 3. Peripheral: Unidirectional, horizontal (may have torsional component), suppresses with fixation 4. Central: Direction-changing, purely vertical, or purely torsional - concerning for stroke
N - Test of Skew (Alternate Cover Test) 1. Cover one eye, then uncover and cover the other 2. Watch for vertical refixation movement 3. Peripheral: No skew deviation 4. Central: Skew deviation present - concerning for stroke
HINTS Interpretation¶
| Finding | Interpretation |
|---|---|
| Abnormal HIT + Unidirectional nystagmus + No skew | PERIPHERAL - Likely vestibular neuritis |
| Normal HIT + Direction-changing nystagmus OR Skew present | CENTRAL - Requires urgent MRI; high stroke probability |
| Any ONE central sign | Treat as CENTRAL until proven otherwise |
HINTS-Plus¶
Add hearing assessment (finger rub test or audiometry): - New unilateral hearing loss with acute vertigo suggests AICA stroke (anterior inferior cerebellar artery) - Presence of hearing loss with "peripheral" HINTS pattern should still raise concern for stroke
Key Points¶
- HINTS is more sensitive than early MRI for posterior circulation stroke (sensitivity 100% vs 72% for MRI within 48 hours)
- Only valid in Acute Vestibular Syndrome (acute, continuous vertigo with nystagmus)
- Not valid for episodic vertigo (e.g., BPPV) or chronic dizziness
- Requires practice to perform reliably; video-HIT more accurate than bedside
APPENDIX B: Dix-Hallpike and Epley Maneuver¶
Dix-Hallpike Test (Diagnostic for Posterior Canal BPPV)¶
Procedure: 1. Patient sitting upright on exam table 2. Turn head 45 degrees toward side being tested 3. Rapidly lower patient to supine with head hanging 20 degrees below table 4. Maintain position for 30-60 seconds observing for nystagmus 5. Return patient to sitting 6. Repeat on opposite side
Positive Test (Posterior Canal BPPV): - Onset delay 2-5 seconds (latency) - Upbeat + torsional nystagmus (top pole of eye toward down ear) - Crescendo-decrescendo pattern - Duration <60 seconds - Fatigues with repetition - Associated vertigo
Concerning Findings (Suggests Central Cause): - No latency (immediate onset) - Pure vertical or horizontal nystagmus - Duration >60 seconds - No fatigue with repetition - No vertigo despite nystagmus
Epley Maneuver (Treatment for Posterior Canal BPPV)¶
Prerequisites: - Positive Dix-Hallpike test - Identify affected side
Procedure (for RIGHT posterior canal): 1. Position 1: Dix-Hallpike position (head turned 45° right, head hanging) - hold 30-60 seconds 2. Position 2: Turn head 90° to left (now looking 45° left) - hold 30-60 seconds 3. Position 3: Roll body to left, head pointing down 45° to floor - hold 30-60 seconds 4. Position 4: Sit up slowly, head still turned left 5. Turn head to center
For LEFT posterior canal: Reverse all directions
Success Rate: 80% single treatment; 90% with repeat maneuvers
Post-Procedure Instructions (Controversial): - Traditional: Sleep propped up 45°, avoid affected side for 24-48 hours - Current evidence: Post-treatment restrictions may not be necessary - Common practice: Avoid provocative positions for 24 hours
APPENDIX C: Supine Roll Test and BBQ Roll Maneuver¶
Supine Roll Test (Diagnostic for Horizontal Canal BPPV)¶
Procedure: 1. Patient supine with head neutral 2. Rapidly turn head 90° to one side, observe for nystagmus (30-60 seconds) 3. Return head to neutral 4. Rapidly turn head 90° to opposite side, observe for nystagmus
Interpretation:
| Type | Nystagmus Direction | Affected Side |
|---|---|---|
| Geotropic (toward ground) | Beats toward ground on both sides; STRONGER side is affected | Side with MORE intense nystagmus |
| Apogeotropic (away from ground) | Beats away from ground on both sides; WEAKER side is affected | Side with LESS intense nystagmus |
Lempert (BBQ Roll) Maneuver (Treatment for Horizontal Canal BPPV)¶
For Geotropic Horizontal Canal BPPV:
- Patient supine, head turned toward AFFECTED ear
- Roll head 90° toward UNAFFECTED side (now facing up) - hold 30-60 seconds
- Roll head another 90° (now facing unaffected side) - hold 30-60 seconds
- Roll body to prone, head turned 90° (nose toward floor) - hold 30-60 seconds
- Continue rolling 90° toward unaffected side - hold 30-60 seconds
- Sit up slowly
Total rotation: 360° away from affected ear
For Apogeotropic variant: May need modified approach or Gufoni maneuver