Vertigo
Red Flags — posterior circulation stroke must be excluded first
| Red flag | Why dangerous | Action |
|---|---|---|
| New headache at onset of vertigo | Sudden onset severe headache with vertigo = posterior fossa haemorrhage (cerebellar bleed) or SAH. Even a mild new headache at the onset of acute vertigo in a hypertensive patient requires CT head urgently. "The worst headache of my life" = SAH pathway immediately. | CT head + 999 |
| Diplopia, dysarthria, or dysphagia | Brainstem involvement — diplopia (ocular nerve nuclei), dysarthria (corticobulbar tracts), dysphagia (vagal and hypoglossal nuclei). Any of these alongside vertigo = posterior circulation stroke until proven by DWI-MRI. 999 immediately — stroke pathway regardless of how mild the symptoms appear. | 999 — stroke pathway |
| Limb weakness or ataxia | Ipsilateral limb ataxia = cerebellar involvement (PICA territory infarct). Contralateral limb weakness = brainstem or corticospinal tract involvement. Either alongside vertigo = posterior circulation stroke. A patient who cannot walk and attributes this to vertigo — perform HINTS and activate stroke pathway. | 999 — stroke pathway |
| HINTS exam suggesting central pathology | HINTS (Head Impulse test, Nystagmus type, Test of Skew) is the bedside examination that differentiates peripheral from central vertigo in acute vestibular syndrome. Central HINTS = normal head impulse (no catch-up saccade) + direction-changing nystagmus + vertical skew deviation → posterior fossa lesion until disproven by MRI. | 999 — immediate stroke pathway |
| Facial numbness or weakness | Facial nerve or trigeminal involvement alongside vertigo localises the lesion to the posterior fossa. Lateral medullary syndrome (Wallenberg): vertigo + ipsilateral facial numbness + contralateral body pain/temperature loss + ipsilateral Horner's syndrome — classic posterior circulation stroke syndrome. | 999 — stroke pathway |
| Sudden hearing loss + severe vertigo | Sudden combined cochlear and vestibular loss = AICA territory infarct (anterior inferior cerebellar artery supplies both the labyrinth and cerebellum). This is a stroke and not labyrinthitis until MRI proves otherwise. 999 immediately. | 999 — AICA stroke pathway |
😰 Fear and Acute Distress
Acute severe rotational vertigo is one of the most distressing symptoms a patient can experience — the inability to stand, persistent vomiting, and the sensation of the world spinning are terrifying, particularly when they have occurred suddenly without warning. Acknowledging this experience empathetically before beginning the clinical assessment significantly improves patient cooperation and comfort.
"I can see this is really frightening — vertigo can be incredibly disabling. I'm going to examine you carefully to understand what's causing it and what we can do."🚗 Driving — Acute Safety Restriction
Acute disabling vertigo requires a driving restriction until fully resolved — DVLA Assessing fitness to drive: a driver liable to sudden and disabling vertigo must not drive and must notify the DVLA; driving may resume once symptoms are satisfactorily controlled (there is no fixed minimum period). This must be addressed at the initial consultation, particularly for a school teacher who may drive to work. The restriction is safety-based and time-limited, not permanent.
"I need to mention that it wouldn't be safe to drive while you're experiencing this level of vertigo — and the DVLA rules say you mustn't drive while you're liable to sudden disabling attacks. Let's review when it's safe to drive again once this is under control."💼 Work and Daily Function
Vestibular neuritis and BPPV can severely impact a teacher's ability to stand at the front of a classroom, write on a board, or move around the school environment. A fit note may be needed for the acute phase. Understanding what the patient does at work allows appropriate advice — the Epley manoeuvre can be performed the same day, potentially resolving BPPV and enabling rapid return to function.
"Given your job, I understand how disabling this must feel. The good news is that if this is the most common type of inner-ear vertigo, there's a very effective treatment we can do right here today that works quickly for most people."😔 Chronic Vertigo and Anxiety
Patients who have had recurrent vertigo attacks (as in Menière's disease or BPPV) develop anticipatory anxiety about future episodes, often restricting their lives — avoiding situations where vertigo might occur, stopping exercise, and withdrawing from social activities. Vestibular rehabilitation explicitly targets this avoidance behaviour alongside physical reconditioning of the vestibular system.
"Some people find that after vertigo episodes, they start avoiding movement because they're frightened it will bring it back — but actually, gentle movement and rehabilitation is the best way to get better faster. Have you been finding yourself doing that?"🤢 Nausea and Wellbeing
The nausea and vomiting of acute vertigo can prevent oral medication, adequate hydration, and engagement with vestibular rehabilitation. Antiemetic medication (prochlorperazine buccal) is both symptom-relieving and necessary for the patient to be able to cooperate with examination and treatment. Its use should be time-limited — prolonged antiemetics impair vestibular compensation.
"The nausea is a really distressing part of this, and I'm going to give you something to help with that first — so we can make you comfortable enough to do the examination and treatment."🏠 Falls Risk and Safety
Acute severe vertigo creates a significant falls risk — particularly in older adults. The inability to stand without support, combined with the tendency to veer toward the affected side (past-pointing, Romberg), means the patient should not be left alone, and their home environment should be assessed for fall hazards. Handrails, shower seats, and carer support may be needed during the acute phase of vestibular neuritis.
"Given how severe this is, I don't want you to be at home alone during the acute phase — is there someone who can be with you? And please make sure you hold on to something when you move."- Not distinguishing true vertigo from presyncope or disequilibrium
- Not screening for neurological red flags before positional testing
- Not asking about episode duration — missing the BPPV vs Menière's vs VN distinction
- Performing Dix-Hallpike before excluding central cause
- Not asking about DVLA driving implications
999 — Stroke Pathway
Do not delay- Any neurological red flag + vertigoHeadache at onset, diplopia, dysarthria, dysphagia, facial numbness, limb weakness/ataxia → 999
- Central HINTS examNormal head impulse (no catch-up saccade) + direction-changing nystagmus + skew deviation → posterior fossa stroke
- Sudden hearing loss + severe vertigoAICA stroke territory — 999 immediately; MRI DWI urgently
- Cerebellar bleed (sudden onset headache + ataxia + vomiting)CT head emergency — neurosurgical referral if cerebellar haematoma
Same-Day / 48-Hour Assessment
Rapid assessment- Acute vestibular syndrome — cannot exclude stroke clinicallyIf HINTS equivocal, not reliable, or no trained clinician available → immediate stroke pathway referral; imaging per local protocol (NICE NG127)
- First attack of Menière's diseaseENT urgent referral for audiogram, tympanometry, and treatment initiation
- BPPV not resolving with Epley after 3 treatmentsENT referral for vestibular assessment; consider atypical canal or central cause
- Vertigo with falls causing injuryUrgent vestibular rehabilitation referral; falls assessment; occupational therapy
Primary Care Management
GP management- BPPV — positive Dix-Hallpike, central features absentEpley manoeuvre in clinic today; Brandt-Daroff exercises at home; review 2 weeks
- Vestibular neuritis (post-viral, peripheral HINTS)Short-course prochlorperazine (2–3 days) + vestibular rehabilitation; no routine steroids; GP review 1 week
- Drug-induced vertigoStop or reduce culprit medication; review in 2–4 weeks
- Recurrent BPPVEpley in clinic; teach Brandt-Daroff for self-management; ENT if more than 3 recurrences/year
"Your balance system uses signals from three places — your inner ear, your eyes, and the pressure sensors in your joints — and your brain combines all three to work out where you are in space. What's happened is that the balance organ in your inner ear has sent an incorrect signal — probably because a tiny crystal has shifted out of place inside the balance organ. When you turn your head, this crystal moves and sends a confusing message to your brain, which interprets it as spinning. The good news is that this is one of the most treatable types of vertigo — there's a specific head movement sequence I can do with you now that repositions the crystal. Most people feel significantly better after just one treatment."
BPPV — Posterior Canal (most BPPV)
Positional rotational vertigo <1 minute triggered by rolling over, looking up. Dix-Hallpike positive: torsional upbeat nystagmus after a latency of a few seconds, fatigues on repeat. Treatment: Epley manoeuvre — most people improve after one or more manoeuvres. Brandt-Daroff exercises for home use. Review in 2 weeks.
Vestibular Neuritis
Acute onset continuous vertigo for days, post-viral, no hearing loss. HINTS peripheral (catch-up saccade on head impulse). Dix-Hallpike negative. Treatment: prochlorperazine (acute, 2–3 days), vestibular rehabilitation; steroids are not started routinely (evidence mixed) — sudden hearing loss follows the urgent ENT pathway (NICE NG98). Resolves over 1–6 weeks.
Menière's Disease
Episodic vertigo (20 min–12 hrs) + unilateral SNHL (fluctuating) + tinnitus + aural fullness. Confirmed by ENT with audiogram. Treatment: acute-attack suppressant only; a betahistine trial may be considered (benefit uncertain); dietary trigger trial without excessive salt restriction; diuretics and intratympanic treatment specialist-led. ENT referral for diagnosis and management.
BPPV — Horizontal or Anterior Canal (Atypical)
Dix-Hallpike negative or atypical; horizontal canal BPPV confirmed by supine roll test (geotropic or ageotropic nystagmus). Requires ENT specialist positional manoeuvre (Gufoni or Barbecue roll) or vestibular physiotherapy. Refer if GP Epley fails after 3 attempts.
Vestibular Migraine
Recurrent episodes of vertigo lasting 5 minutes to 72 hours associated with migraine features (headache, photophobia, phonophobia). No clear central HINTS findings. ENT or neurology referral for diagnosis. Treated as migraine prophylaxis plus vestibular rehabilitation.
Posterior Circulation Stroke / TIA
HINTS central features + vascular risk factors. PICA (posterior inferior cerebellar artery) → Wallenberg syndrome. AICA (anterior inferior cerebellar artery) → vertigo + sudden hearing loss + ipsilateral facial numbness. HINTS: normal head impulse, direction-changing nystagmus, skew deviation → 999. MRI DWI urgently.
Cerebellar Haemorrhage
Sudden onset severe vertigo + headache + inability to stand + vomiting in a hypertensive patient. CT head emergency. Neurosurgical referral if cerebellar haematoma with mass effect. 999 immediately. Do not attribute to BPPV without CT exclusion of haemorrhage in a hypertensive patient with severe acute presentation.
Validate
Acknowledge how frightening acute vertigo is before any clinical explanation.
"I can see this has been really terrifying — sudden severe spinning and vomiting is one of the most distressing things to experience. I want to reassure you that I'm going to examine you carefully to understand exactly what's happening."Explain
Explain the HINTS exam and why it is actually more informative than a brain scan in the first 48 hours — this is counterintuitive but builds confidence in the examination.
"I'm going to do a specific clinical eye examination now — and actually, for the type of vertigo you have, this bedside test is more sensitive for detecting a brain problem than an MRI scan in the first 48 hours. So this is the most important test we can do right now."Offer
If BPPV is confirmed — offer the Epley manoeuvre today. The immediate treatment offer transforms the consultation from a diagnostic to a therapeutic encounter.
"The good news is that if this is the type I think it is — the crystal type — I can treat it right here today with a specific head movement sequence. Most people feel significantly better immediately afterwards."The Epley manoeuvre repositions otoliths (calcium carbonate crystals) that have drifted from the utricle into the posterior semicircular canal, moving them out of the canal and back into the utricle through a series of sequential head positions that use gravity to guide the crystals. Each position is held until vertigo and nystagmus settle, and for at least about 30 seconds.
1. Dix-Hallpike to affected side (hold ≥30 sec, until settled). 2. Rotate head 90° to opposite side (hold as above). 3. Roll body toward unaffected side, head now facing floor (hold as above). 4. Sit patient up slowly. 5. Head returns to midline. No routine post-manoeuvre restrictions (sleeping upright, collar) are needed.
Brandt-Daroff exercises habituate the central nervous system to the abnormal vestibular signal by repeated exposure — less specific than Epley but easy to self-administer and effective for residual or recurrent symptoms. Also suitable for patients who cannot tolerate the Epley manoeuvre.
Sit upright → rapidly lie on affected side (head 45° toward ceiling) → hold 30 sec or until vertigo stops → return to sitting → hold 30 sec → lie on opposite side → hold 30 sec. Repeat 5 times per session, twice daily, for 2 weeks.
Vestibular rehabilitation physiotherapy promotes central compensation for peripheral vestibular deafferentation through structured exercises — gaze stabilisation, habituation exercises, and balance training. The cornerstone of vestibular neuritis management and significantly more effective than antiemetics as a long-term treatment.
Refer to community vestibular physiotherapy or ENT physiotherapy service. Programme typically 8 sessions over 6 weeks. Exercises must be done consistently — avoiding movement (common in patients with vertigo) dramatically slows recovery and maintains disability.
DVLA Group 1 (car): must not drive while experiencing disabling vertigo. Can resume when symptoms are satisfactorily controlled and unlikely to cause sudden disabling recurrence; notify the DVLA if attacks are sudden and disabling (no fixed minimum period in DVLA guidance). Group 2 (HGV/bus): specialist assessment required before return to driving.
Advise explicitly: "You should not drive until the vertigo has resolved or is well controlled and you are not at risk of sudden disabling attacks." Document this advice in the clinical notes. Notify the patient that they must inform the DVLA if episodes are recurrent and disabling.
During acute phase of vestibular neuritis or severe BPPV: remove trip hazards; hold handrails at all times; shower seated if possible; do not climb ladders or stairs alone; ensure someone is at home. Occupational therapy falls assessment if recurrent or severely impaired.
Prochlorperazine provides acute symptom relief for nausea and vertigo — but if continued beyond 2–3 days it suppresses the central compensation mechanism that allows the brain to adapt to vestibular deafferentation. Long-term antiemetics for vertigo significantly prolong disability and are one of the most common management errors in vestibular disorders.
"This tablet will help with the nausea and spinning sensation in the short term. It's very important that you take it for no more than 3 days — after that, the tablet actually slows down your brain's ability to adapt and recover. The recovery really comes from the exercises, not the tablet."
The most examinable prescribing point for prochlorperazine in vestibular disorders: maximum 2–3 days. Prescribing it long-term for chronic dizziness is a very common error in primary care and is specifically tested in the SCA. "I'm giving you this for the acute symptoms, but we'll stop it after 3 days — longer than that actually slows recovery."
"Steroid tablets haven't been shown clearly to help this kind of balance-nerve inflammation, so I won't start them routinely. What speeds recovery is moving and the balance exercises. If your hearing suddenly drops, contact us the same day — that needs an ear specialist within 24 hours."
Steroids for vestibular neuritis are not started routinely in primary care — the evidence is mixed (Cochrane review, Fishman 2011: insufficient evidence from small trials); steroid decisions for sudden hearing loss belong to the urgent ENT pathway (NICE NG98). Pairing this with the explicit statement "maximum 2–3 days of prochlorperazine" demonstrates systematic management thinking.
"This tablet needs to be taken three times a day every day — it works by reducing the fluid pressure in the inner ear, which is what causes your attacks. You won't feel it working immediately, and it doesn't help everyone — we'll review it at 3 to 6 months and stop it if it isn't helping."
Key SCA point: betahistine is for confirmed Menière's only. "I wouldn't start betahistine today — we need ENT to confirm the diagnosis first with a formal hearing test." This demonstrates safe prescribing and the importance of not jumping to treatment before diagnosis is established.
"I'm not giving you aspirin right now — the hospital needs to scan your brain first to make sure there is no bleeding, and they will start the right treatment straight after. The ambulance is on its way."
NICE NG128: in acute stroke, aspirin 300 mg is given only after brain imaging has excluded haemorrhage — so do not give it in the surgery while awaiting 999; for suspected TIA with resolved symptoms, start aspirin 300 mg immediately. Stating this distinction clearly while arranging 999 transfer demonstrates safe emergency management and scores in Tasks.
Fear of Recurrence
After a first episode of BPPV or vestibular neuritis, patients develop significant fear of recurrence — particularly when triggers (position change for BPPV, sudden head movements for VN) are unavoidable in daily life. Anticipatory anxiety leads to avoidance of any head movement, which paradoxically delays vestibular compensation and prolongs recovery.
The most important rehabilitation instruction is to move despite the discomfort — habituation exercises work by exposing the vestibular system to the triggering stimulus repeatedly until the central nervous system stops perceiving it as a problem. Avoidance is the enemy of recovery.
"I know it's tempting to keep very still when you're dizzy, but actually the more you move — carefully and safely — the faster your balance system will adapt and recover. Avoiding movement is the one thing that makes recovery slower."Driving and Occupation
A teacher with acute disabling vertigo cannot drive to work and cannot stand at the front of a classroom safely — at least in the acute phase. A fit note for the acute phase may be needed. DVLA advice (no driving while liable to sudden disabling vertigo) must be given and documented at this consultation.
The good news for BPPV: the Epley manoeuvre often resolves symptoms within minutes to hours, enabling a rapid return to function. For vestibular neuritis, the acute phase lasts 1–3 weeks — a fit note for this period is appropriate, with review at the end of that period.
"Given how severe this is right now, I'm going to give you a fit note for the next 1–2 weeks — and I'd like you to come back then so we can see how the recovery is going and when it's safe to return."Chronic Dizziness and Functional Disorder
Persistent Postural-Perceptual Dizziness (PPPD) is a functional vestibular disorder that develops in a significant proportion of patients following acute vestibular events. The patient continues to experience chronic dizziness long after the acute event has resolved, driven by maladaptive neural compensation and anxiety.
PPPD is managed with vestibular rehabilitation, CBT, and SSRIs in selected cases — not with antiemetics. Recognising this transition from acute organic vertigo to functional dizziness is important; it changes the management from investigation to rehabilitation and psychological support.
"Sometimes after vertigo, the dizziness can linger longer than the original cause would explain — this is quite common and it's something we address with specific exercises and, in some cases, talking therapy. It's very treatable."Falls and Home Safety
Acute severe vertigo is a significant falls risk — particularly in older adults or those with pre-existing balance difficulties. The combination of vestibular deafferentation, postural instability, and vascular risk factors (in this patient: hypertension) creates a dangerous context for falls with potentially serious consequences.
Practical acute phase advice: remove trip hazards, use handrails, shower seated, do not climb ladders or stairs alone, have someone at home during the acute phase. Occupational therapy falls assessment if recurrent or severely impaired after the acute phase.
"For the next few days while the vertigo is at its worst, please make sure you're holding on to something whenever you move, and that there's someone with you at home — the risk of a fall is real and I don't want you to get hurt."2 Weeks — BPPV response to Epley
If BPPV: check whether Epley resolved symptoms. If resolved → reassure; Brandt-Daroff as ongoing prevention; DVLA review. If not resolved → repeat Epley (up to 3 times before ENT referral). If vestibular neuritis: assess recovery; stop prochlorperazine if still on it; vestibular rehabilitation under way.
4–6 Weeks — Recovery assessment + return to driving
Review vestibular neuritis recovery; assess readiness to return to driving (once symptoms are controlled and sudden disabling attacks are unlikely); vestibular rehab progress; PHQ-9 if anxiety or chronic dizziness developing; fit note review for return to work.
3 Months — If symptoms persist
If dizziness persists beyond 6 weeks after vestibular neuritis → consider PPPD; refer vestibular physiotherapy. If BPPV recurring frequently → ENT referral; explore horizontal canal variant. Audiogram if any hearing change has developed since presentation.
⚠ Three scenario-specific phrases
- Prescribing long-term prochlorperazine without the 3-day limit
- Performing Epley without first doing HINTS exam
- Not mentioning DVLA driving restriction
- Not giving neurological red flag safety-net
- Not offering Epley manoeuvre in clinic when BPPV is confirmed
- Diagnosing BPPV without Dix-Hallpike test
- Neurological red flags screened before positional testing
- HINTS exam performed and interpreted correctly
- Dix-Hallpike only after peripheral HINTS confirmed
- Epley manoeuvre offered and performed in clinic (BPPV)
- Prochlorperazine prescribed with explicit 3-day maximum
- DVLA driving advice (no driving while liable to sudden disabling vertigo) given and documented
- Acknowledged how frightening acute vertigo is
- Stroke concern named and addressed directly before examination
- HINTS exam explained as more sensitive than MRI in first 48 hours
- Epley offered as treatment today — transformed expectation
- Falls risk and home safety discussed with genuine concern
- Closing question asked before the Epley is performed
Who you are
Helen Okafor, 57, secondary school teacher. Woke this morning and when she rolled over in bed the room started spinning violently. Vomited twice. Now sitting very still in the GP chair. Describes the spinning as definitely the room moving — not lightheadedness. Hypertension on amlodipine 10 mg + ramipril 5 mg. BMI 32. No headache. No diplopia, slurred speech, or weakness. No hearing change. No recent viral illness.
Hidden concern
You are convinced this is a stroke. Your father died of a stroke at 62, and you know you have high blood pressure. Will not say this directly unless asked — but if the doctor asks "Is there something specific you're worried this might be?" → "My dad died of a stroke — I thought this is what it must feel like."
Symptoms if asked
- Spinning started when she rolled over in bed — to the right side
- Worst in the first 30 seconds, then settles a bit
- Happens every time she moves her head
- No spinning when sitting completely still
- No headache, no double vision, no speech difficulty, no weakness
- Hearing is normal — no change noticed
Responses and challenges
- If MRI is offered: "Shouldn't I have a brain scan to be safe?" → responds positively if HINTS superiority is explained
- If Epley is offered: initially reluctant ("Moving my head sounds terrifying") → agrees if it is explained that most people improve after one or more manoeuvres
- On driving: "I need to drive to school — is there any flexibility?" → accepts restriction when safety framed empathetically
- On prochlorperazine: "Can't I just take the tablets for longer to get through this?" → accepts 3-day limit if the recovery rationale is explained clearly
Resolution: Helen accepts the diagnosis and treatment if the candidate: (1) directly names her stroke fear and addresses it before examining; (2) explains HINTS as more sensitive than MRI in first 48 hours; (3) performs or clearly describes the Epley manoeuvre; (4) gives the 3-day prochlorperazine limit with clear rationale; (5) addresses DVLA with empathy for its impact on her work as a teacher. She will ask about an MRI — this is the key expectation management moment of the consultation.
- Headache at onset
- Diplopia/dysarthria/dysphagia
- Limb weakness or ataxia
- Central HINTS (normal HIT, direction-changing Nystagmus, Skew deviation)
- Sudden hearing loss + severe vertigo (AICA)
- Peripheral HINTS (catch-up saccade, direction-fixed Nystagmus, no Skew)
- BPPV: Dix-Hallpike + Epley in clinic
- Vestibular neuritis: short antiemetic + rehab
HIT: Catch-up saccade PRESENT ✓
Nystagmus: Direction-FIXED ✓
Skew: NO vertical skew ✓
Central (any 1 = red flag):
HIT: No catch-up saccade ✗
Nystagmus: Direction-CHANGING ✗
Skew: Skew deviation PRESENT ✗
→ Neurological red flags → HINTS → Dix-Hallpike. This sequence is non-negotiable.
→ "This is for 3 days only — longer than that actually slows your recovery by interfering with the brain's ability to adapt"
→ "Are you worried this might be a stroke? That's a very understandable thing to be concerned about with these symptoms."
→ "If the test is positive, I can treat it right here today — there's a specific head movement sequence that works for most people immediately"
→ "You should not drive until the vertigo is gone or well controlled — and that advice needs to be documented in your notes today"
→ The diagnosis of BPPV requires a positive Dix-Hallpike. "I think this might be BPPV — let me do the specific test to confirm it"
→ "If the vertigo returns and you have any headache, double vision, or weakness — 999 immediately"
→ Immediate stroke pathway referral — imaging per local protocol; an early normal CT does not exclude posterior circulation stroke