SCOPE: Evaluation and management of acute vertigo and dizziness in adults. Covers differentiation of peripheral vs. central causes, the HINTS exam, Dix-Hallpike and canalith repositioning maneuvers, evaluation for posterior circulation stroke, and management of common vestibular disorders (BPPV, vestibular neuritis, Meniere's disease, vestibular migraine). Excludes chronic non-specific dizziness (persistent postural-perceptual dizziness), medication-induced dizziness (covered briefly), and presyncope/orthostatic hypotension (separate evaluation).
PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting
HINTS exam (Head Impulse, Nystagmus, Test of Skew)
STAT
STAT
ROUTINE
STAT
CRITICAL bedside exam; must be performed in patient with ACUTE VESTIBULAR SYNDROME (continuous vertigo, nausea, nystagmus, gait instability); performed by trained examiner; more sensitive than early MRI for stroke
Peripheral pattern (benign): Positive head impulse (catch-up saccade), horizontal nystagmus with unidirectional fast phase, no skew deviation; Central pattern (concerning for stroke): Negative/normal head impulse, direction-changing or vertical nystagmus, skew deviation
Cannot perform if patient not having acute continuous vertigo; requires examiner training
CT head without contrast (CPT 70450)
STAT
STAT
-
STAT
NOT sensitive for posterior fossa stroke (sensitivity ~20-40%); useful for hemorrhage; may be appropriate for trauma or if MRI not available; does NOT rule out posterior circulation stroke
Cerebellar or brainstem hemorrhage; mass lesion; hydrocephalus; NEGATIVE CT does NOT exclude stroke in posterior circulation
None for non-contrast
MRI brain with DWI (CPT 70551)
URGENT
URGENT
ROUTINE
URGENT
Gold standard for posterior circulation stroke; DWI highly sensitive for acute ischemia; HOWEVER: Early MRI (<48h) can miss 12-20% of small posterior fossa strokes — clinical (HINTS) may be more sensitive; repeat MRI if high suspicion and initial negative
Diagnostic for BPPV (posterior canal, most common); performed on ALL patients with episodic positional vertigo; positive if nystagmus and vertigo provoked with latency and limited duration
Diagnostic for horizontal canal BPPV; patient supine, rapidly turn head 90° to each side; geotropic (toward ground) or apogeotropic (away from ground) horizontal nystagmus
Horizontal nystagmus provoked by head turning; geotropic (canalithiasis) vs. apogeotropic (cupulolithiasis)
Same as Dix-Hallpike
Audiometry (CPT 92557)
-
URGENT
ROUTINE
-
Essential if hearing loss suspected (Meniere's disease, labyrinthitis, vestibular schwannoma); sudden sensorineural hearing loss is emergency
25-50 mg :: IV :: q6h :: Acute severe vertigo: Meclizine 25-50 mg PO q6-8h; OR Dimenhydrinate (Dramamine) 50 mg PO/IV q6h; OR Promethazine 25 mg PO/IM/IV q6h; OR Ondansetron 4-8 mg IV/PO q8h (for nausea); IV fluids for dehydration from vomiting; Diazepam 2-5 mg IV/PO for severe acute vertigo (benzodiazepines are potent vestibular suppressants)
-
Short-term use only (24-72h); vestibular suppressants interfere with central compensation if used chronically; avoid in suspected central cause until stroke ruled out
STAT
STAT
ROUTINE
STAT
IV fluids
IV
-
N/A :: IV :: per protocol :: If dehydrated from vomiting; NS or LR bolus then maintenance; assess orthostatic hypotension
-
Supportive care; correct volume depletion
STAT
STAT
-
STAT
Antiemetics
IV
-
4-8 mg :: IV :: - :: Ondansetron 4-8 mg IV/PO; metoclopramide 10 mg IV (avoid in elderly — EPS); prochlorperazine 5-10 mg IV/IM
-
Nausea is often the most debilitating symptom
STAT
STAT
ROUTINE
STAT
Rule out stroke
-
-
N/A :: - :: per protocol :: If ANY central features on HINTS: STAT MRI with DWI; vascular imaging (MRA or CTA); neurology/stroke consultation; Central features: Normal/negative head impulse test, vertical or direction-changing nystagmus, skew deviation, focal neurologic signs, severe imbalance (cannot walk), hearing loss + vertigo without Meniere's history
-
HINTS is more sensitive than early CT or MRI for posterior circulation stroke; do NOT rely on negative CT to exclude stroke
90% :: - :: - :: For BPPV (positive Dix-Hallpike): Immediately perform Epley maneuver; highly effective (80-90% single treatment); may repeat if symptoms persist; send home with instructions for home Epley or Brandt-Daroff exercises
-
Epley is definitive treatment for posterior canal BPPV; medications are NOT indicated for BPPV — repositioning maneuvers are the treatment
N/A :: - :: per session :: Standard canalith repositioning; patient starts seated, Dix-Hallpike position for 30 sec, rotate head 90° toward opposite side (30 sec), roll body to face down with head still turned (30 sec), sit up; NNT = 2-3 for resolution
-
First-line treatment for posterior canal BPPV; highly effective; may repeat same day or next visit
-
-
-
-
Semont maneuver (alternative)
-
-
N/A :: - :: per session :: Alternative to Epley; patient moved rapidly from side to side; less commonly used but effective
-
Alternative if Epley difficult or ineffective
-
-
-
-
BBQ roll (Lempert maneuver) — horizontal canal
-
-
N/A :: - :: per session :: For horizontal canal BPPV; patient rotates 360° along long axis of body (log roll) toward unaffected side; 90° increments with 30 sec pauses
-
Treatment for horizontal canal BPPV; geotropic variant
-
-
-
-
Brandt-Daroff exercises (home)
-
-
N/A :: - :: per session :: Patient alternates lying on each side x 30 sec, 10-20 repetitions, 3x daily; habituates symptoms; less effective than Epley for posterior canal
-
Adjunctive home therapy; may help with residual symptoms; promotes compensation
-
-
-
-
Avoid vestibular suppressants for BPPV
-
-
N/A :: - :: N/A :: Do NOT prescribe meclizine for ongoing BPPV treatment; medications delay compensation and do not address the mechanical problem
-
BPPV is a mechanical problem (otoliths); repositioning is definitive treatment
-
-
-
-
Post-treatment instructions
-
-
N/A :: - :: once :: Avoid lying flat for 1-2 nights (sleep propped up); avoid rapid head movements for 24-48h; avoid affected side lying for 1 week (controversial but commonly recommended)
1 mg/kg :: - :: daily x 10 days :: Prednisone 1 mg/kg/day (max 60 mg) x 10 days with taper OR methylprednisolone 100 mg x 3 days then taper; start within 72 hours of symptom onset for best benefit
-
Strupp et al. (2004): Steroids improve vestibular function recovery in vestibular neuritis; start early; NNT ~4 for complete recovery
-
-
-
-
Antivirals (controversial)
PO
-
1000 mg :: PO :: TID :: Valacyclovir 1000 mg TID x 7 days; evidence is WEAK; some use empirically if early presentation; thought to be HSV reactivation (like Bell's palsy)
-
Cochrane review: No clear benefit; some clinicians still use empirically, especially if labyrinthitis with hearing loss
-
-
-
-
Vestibular suppressants (short-term only)
PO
-
25 mg :: PO :: q8h :: Meclizine 25 mg q8h OR dimenhydrinate 50 mg q6h OR diazepam 5 mg BID x 1-3 days ONLY; taper off as soon as tolerated
-
Short-term symptom relief; STOP after 72 hours maximum — prolonged use delays compensation
-
-
-
-
Early vestibular rehabilitation
-
-
N/A :: - :: daily :: Refer to vestibular physical therapy; gaze stabilization exercises; balance training; habituation exercises; START EARLY (as soon as acute symptoms controlled)
-
Cochrane review: Vestibular rehabilitation is effective for unilateral vestibular hypofunction; early initiation improves outcomes
-
-
-
-
Education
-
-
N/A :: - :: once :: Explain natural history (acute symptoms resolve over days to weeks; full compensation may take weeks to months); reassurance; avoid prolonged bed rest
N/A :: IV :: per protocol :: If central cause suspected or identified: acute stroke protocol; consider IV thrombolysis (tPA/tenecteplase) if within window; endovascular therapy for basilar artery occlusion; aspirin if not tPA candidate; admit to stroke unit
-
Posterior circulation stroke is life-threatening; basilar artery occlusion has >80% mortality if untreated
-
-
-
-
Secondary stroke prevention
-
-
N/A :: - :: daily :: Dual antiplatelet therapy (aspirin + clopidogrel x 21 days per CHANCE/POINT); statin; BP control; diabetes management; address vascular risk factors
-
Per acute ischemic stroke guidelines
-
-
-
-
Anticoagulation (if indicated)
-
-
N/A :: - :: per protocol :: If vertebral artery dissection or cardiac source (atrial fibrillation, PFO with high-risk features)
Must be performed by trained examiner in patient with CONTINUOUS vertigo and nystagmus; more sensitive than CT/early MRI for stroke; see HINTS protocol in appendix
Dix-Hallpike maneuver
STAT
STAT
ROUTINE
STAT
Perform on ALL patients with EPISODIC POSITIONAL vertigo; diagnostic for BPPV; if positive → Epley maneuver
Neurology consultation
-
URGENT
ROUTINE
URGENT
If central cause suspected; diagnostic uncertainty; refractory symptoms; atypical features
Stroke consultation
STAT
STAT
-
STAT
If HINTS suggests central cause; any concern for posterior circulation stroke
Confirmed or highly suspected posterior circulation stroke; basilar artery occlusion; cerebellar stroke with mass effect/hydrocephalus
General floor
Intractable vomiting/dehydration requiring IV fluids and monitoring; diagnostic uncertainty requiring observation and further testing; elderly with high fall risk and no safe home environment
Observation
Prolonged symptoms requiring IV fluids and antiemetics; need for serial neurologic exams; MRI pending
HINTS exam (H: head impulse; I: nystagmus; TS: test of skew) was 100% sensitive and 96% specific for stroke in acute vestibular syndrome; superior to MRI in first 24-48h
HINTS should be performed in acute vestibular syndrome; more sensitive than early MRI
Important: HINTS should ONLY be performed in the Acute Vestibular Syndrome (continuous vertigo/nystagmus lasting >24h). It is NOT valid for episodic vertigo (BPPV, Meniere's, vestibular migraine).
Prerequisites:
- Patient has ACUTE VESTIBULAR SYNDROME: Continuous vertigo >24h, nausea/vomiting, nystagmus, gait instability
- Patient has SPONTANEOUS nystagmus visible at rest or with fixation removed
- Examiner is trained in performing and interpreting HINTS
1. HEAD IMPULSE TEST (HIT)
- Patient fixates on examiner's nose
- Examiner holds patient's head and delivers small, rapid, unpredictable horizontal head turns (10-20°)
- NORMAL (dangerous): Eyes stay on target without corrective saccade
- ABNORMAL (reassuring): Corrective saccade back to target after head turn (eyes "catch up")
2. NYSTAGMUS EVALUATION
- Observe spontaneous nystagmus in primary gaze
- Then observe in right gaze and left gaze
- PERIPHERAL (reassuring): Unidirectional — fast phase always beats the same direction regardless of gaze
- CENTRAL (dangerous): Direction-changing — fast phase beats right on right gaze, left on left gaze; OR vertical; OR purely torsional
3. TEST OF SKEW (Alternate Cover Test)
- Patient fixates on target
- Cover one eye, then quickly move cover to other eye
- Watch for vertical correction movement of uncovered eye
- NEGATIVE (reassuring): No vertical movement
- POSITIVE (dangerous): Vertical refixation (eye moves up or down when uncovered)
Interpretation:
- ALL THREE peripheral pattern = Peripheral vestibular lesion (vestibular neuritis)
- ANY ONE central pattern = Central lesion likely → Urgent MRI, stroke workup
For LEFT posterior canal BPPV, mirror all directions
Starting position: Patient sitting on exam table, head turned 45° to the RIGHT
Position 1: Rapidly lay patient back with head hanging over edge of table, still turned 45° right (Dix-Hallpike position); wait 30 seconds (or until nystagmus stops)
Position 2: Rotate head 90° to the LEFT (now 45° left of midline); wait 30 seconds
Position 3: Roll patient onto LEFT side, rotating head another 90° so nose points toward floor; wait 30 seconds
Position 4: Slowly bring patient up to sitting position, keeping head turned left
Finally: Turn head back to midline
Post-procedure:
- May rest for a few minutes
- Sleep with head elevated 45° for 1-2 nights (controversial but commonly recommended)
- Avoid lying on affected side for 1 week
- May need repeat maneuver if symptoms persist
Turn patient's head 45° toward the side being tested (e.g., RIGHT)
While supporting head, rapidly lay patient backward with head hanging 20-30° below table edge
Observe eyes for nystagmus
Positive result for RIGHT posterior canal BPPV:
- Upbeating-torsional nystagmus (top of eye beats upward and toward the RIGHT ear)
- Latency: 2-20 seconds before nystagmus appears
- Duration: <60 seconds (typically 10-40 seconds)
- Fatigable: decreases with repetition
- Patient experiences vertigo
If positive: Proceed immediately to Epley maneuver
Caution: Modify technique for cervical spine disease (use side-lying Dix-Hallpike)
Exercise 1 (VOR x 1):
- Hold a business card at arm's length with a word or letter on it
- Keep the card still and move your head side to side while keeping the word in focus
- Start slowly, gradually increase speed
- 1-2 minutes, 3-5 times daily
Exercise 2 (VOR x 2):
- Move both the card and your head in opposite directions
- Keep the word in focus
- More challenging; progress when VOR x 1 is easy
BALANCE EXERCISES
Standing balance progression:
1. Feet together, eyes open → eyes closed
2. Semi-tandem stance (heel touching arch), eyes open → eyes closed
3. Tandem stance (heel to toe), eyes open → eyes closed
4. Single leg stance, eyes open → eyes closed
Hold each position 30-60 seconds; use wall for safety
Full vestibular testing (VNG); consider PPPD; psychology eval
This template represents the initial build phase (Skill 1) and requires validation through the checker pipeline (Skills 2-6) before clinical deployment.