ENT · Full case

Vertigo

NICE CKS Bárány 2022

79%Dix-Hallpike sensitivity for BPPV

90 secHold time at each Epley position

85%BPPV resolution rate with single Epley

1 weekVestibular neuritis acute phase duration

20–12 hrsMenière's attack duration (episodic)

HINTSHead Impulse·Nystagmus·Test of Skew

4 weeksDVLA off driving — acute disabling vertigo

3 canalsPosterior canal BPPV = 90% of cases

📋 Clinical Stem — Acute Vertigo in a Middle-Aged Adult

A 57-year-old woman presents with sudden-onset vertigo and vomiting — differentiate BPPV, vestibular neuritis, and posterior circulation stroke

"Mrs Helen Okafor, 57, a secondary school teacher. She presents with sudden-onset severe rotational vertigo that started this morning when she rolled over in bed. The room is spinning. She has vomited twice. She finds it very difficult to stand or walk. No headache. No hearing loss. No diplopia or dysphagia. No weakness or numbness. Her vascular risk factors: hypertension (amlodipine 10 mg OD, ramipril 5 mg OD), BMI 32, non-smoker, drinks 12 units alcohol per week. The vertigo is there at rest but dramatically worse when she moves her head."

The sudden onset on head movement (rolling over in bed) with positional worsening strongly suggests BPPV. However, the severity of her presentation and her vascular risk factors (hypertension, obesity) mean a posterior circulation stroke must be actively excluded — not assumed absent. The HINTS exam (Head Impulse test, Nystagmus type, Test of Skew) is the primary clinical tool for distinguishing peripheral from central vertigo at the bedside, and is more sensitive than MRI in the first 48 hours of posterior fossa stroke.

Scenario A — BPPV (Classic) Vertigo with position change (rolling over, looking up), brief (<1 min), Dix-Hallpike positive (torsional upbeat nystagmus, fatigues, latency 2–5 sec). Normal HINTS. Epley manoeuvre in clinic.

Scenario B — Vestibular Neuritis Sustained vertigo for days following a viral illness, worse with movement, no hearing loss, HINTS: normal head impulse test (actually abnormal — catch-up saccade present = peripheral), direction-fixed nystagmus, no skew. Prochlorperazine + prednisolone + vestibular rehabilitation.

Scenario C — Posterior Circulation Stroke (AICA/PICA) Acute vertigo + new headache, diplopia, dysarthria, facial numbness, ipsilateral limb ataxia, or contralateral limb weakness. HINTS: normal head impulse (no catch-up saccade), direction-changing nystagmus, skew deviation present. 999 immediately — stroke pathway.

Scenario D — Menière's Disease Episodic vertigo lasting 20 minutes to 12 hours, associated ipsilateral SNHL (fluctuating), tinnitus, aural fullness. Attacks spontaneous, not positional. ENT referral; betahistine; salt restriction; diuretic.

Scenario E — Drug-Induced Vertigo New medication (aminoglycosides, loop diuretics, antiepileptics, antihypertensives causing postural hypotension) temporally correlated with onset. Medication review first; stop culprit; reassess.

Key variables Was onset positional or spontaneous? Duration of each episode (seconds = BPPV; days = vestibular neuritis; 20 min–12 hrs = Menière's). HINTS exam result. Associated neurological symptoms (headache, diplopia, dysarthria, weakness). Hearing change. Vascular risk factor profile.

Steps:

Step 1

History Taking — Open Question First · Targeted Questions · ICE · Psychosocial Context

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The history in vertigo is dominated by two questions: What is the character of the dizziness? (true rotational vertigo vs presyncope vs disequilibrium — these have completely different differentials) and What is the temporal pattern? (episodic brief = BPPV; episodic moderate = Menière's; sustained days = vestibular neuritis; acute constant = posterior fossa stroke). The neurological red flag screen must be completed before any positional testing is performed.

🎓 Consultation opener

"That sounds really frightening and I can imagine it's quite distressing — before I ask you anything specific, can you describe exactly what this dizziness is like? Is the room spinning, or is it more of a lightheaded or off-balance feeling?"

Distinguishing true rotational vertigo from presyncope or disequilibrium at the opening is the most important single question in any dizziness presentation — the diagnosis flows directly from the answer.

1A — Characterise the vertigo: type, temporal pattern, triggers

Question to ask	Why it matters clinically	Changes what?
🟢 OPEN QUESTION"Can you describe what the dizziness is like — is the room spinning around you, or is it more of a lightheaded or unsteady feeling?"	The type of dizziness is the single most important discriminating factor. True rotational vertigo (room or self spinning) = vestibular cause (BPPV, vestibular neuritis, Menière's, central). Presyncope (lightheaded, grey-out) = cardiovascular cause. Disequilibrium (unsteady without spinning) = cerebellar, proprioceptive, or medication-related. Multisensory dizziness in older adults is a separate category.Never conflate "dizziness" across these categories. The examiner expects you to establish the type of dizziness before making any diagnosis or performing any positional testing.	DiagnosesRisk
Is it related to head position?"Does the spinning happen when you change position — rolling over in bed, looking up, bending down?"	Positional triggering is the hallmark of BPPV — otoliths displaced into the semicircular canals respond to gravity with each position change. Vertigo that is purely positional, brief (<1 minute), and reproducible is highly likely to be BPPV. Vertigo present at rest regardless of position suggests a different mechanism (vestibular neuritis, central pathology).The specific movement that triggers BPPV: rolling over in bed is the most common trigger (especially rolling toward the affected ear). Looking up (top-shelf vertigo) = posterior canal BPPV affecting both ears on upward gaze.	BPPV vs other
How long does each episode last?"When the vertigo comes on, how long does it last — seconds, minutes, hours, or does it stay all day?"	Duration is one of the most diagnostically useful single features: Seconds (<1 minute) = BPPV (otolith settling in canal). 20 minutes–12 hours = Menière's disease (endolymphatic hydrops). Days (continuous, improving over 1–3 weeks) = vestibular neuritis. Constant from onset = central pathology (posterior circulation stroke) or acute labyrinthitis.A patient who says "the room has been spinning continuously for 3 days" has vestibular neuritis or a central cause — not BPPV. This duration question alone narrows the differential dramatically.	DDx
Neurological red flags — screen first"Any headache when the vertigo started? Any double vision, slurred speech, difficulty swallowing? Any weakness or numbness in your face, arm, or leg?"	This is the critical safety question — the most dangerous diagnosis in vertigo is posterior circulation stroke/TIA. Key red flags: new headache at onset (SAH/posterior fossa haemorrhage), diplopia, dysarthria, dysphagia, facial numbness, limb ataxia or weakness, or sudden onset vertigo in a patient with high vascular risk. Any of these = 999 immediately.The HINTS exam (bedside examination) is more sensitive for posterior fossa stroke than MRI in the first 48 hours — a critical caveat that every GP should know. A normal HINTS in the right hands is more reassuring than a normal MRI in acute vertigo.	Emergency if positiveCentral vs peripheral
Associated hearing change or tinnitus?"Have you noticed any change in your hearing, or any ringing in your ears, since the vertigo started?"	Vertigo + ipsilateral SNHL + tinnitus = Menière's disease (or AICA territory stroke — the anterior inferior cerebellar artery supplies both the labyrinth and the cerebellum). Vertigo without hearing change = vestibular neuritis (8th nerve dysfunction without cochlear involvement) or BPPV. Acute vestibular syndrome with sudden hearing loss = AICA infarct until excluded.Sudden hearing loss + severe vertigo = AICA stroke until proven otherwise by MRI. Do not diagnose labyrinthitis without excluding a posterior fossa infarct in this presentation.	Menière's vs VN vs AICAIf acute hearing loss + vertigo
Recent viral illness?"Have you had a cold, flu, or ear infection in the 1–3 weeks before this started?"	Vestibular neuritis classically follows a viral upper respiratory tract infection by 1–3 weeks — the virus (most commonly herpes simplex type 1 reactivation) infects the vestibular nerve causing acute unilateral vestibular deafferentation. In the context of post-viral onset, sustained vertigo lasting days is reassuring as vestibular neuritis (peripheral) rather than a stroke.Vestibular neuritis produces the most severe acute vertigo of any peripheral cause — the severity of the vertigo alone does not distinguish it from a central lesion. The HINTS exam is still needed.	Vestibular neuritisPrednisolone
Vascular risk factors?"Do you have high blood pressure, diabetes, or have you had a stroke or heart attack before?"	High vascular risk (hypertension, diabetes, AF, IHD, previous stroke) raises the pre-test probability of a posterior circulation stroke as the cause of acute vertigo — even if the history sounds peripheral. HINTS exam becomes even more important in high-risk patients. A "normal" positional vertigo history in a 70-year-old with AF still requires a thorough central exclusion.In this stem: Mrs Okafor has hypertension, obesity, and is 57 — her vascular risk is not trivial. The HINTS exam is mandatory before reassuring her.	Stroke riskRisk stratification
Medication review"Have any new medications been started recently? Do you take any tablets that can affect balance or blood pressure?"	Many medications cause dizziness or vertigo: antihypertensives (postural hypotension), antiepileptics (phenytoin, carbamazepine — cerebellar toxicity), aminoglycosides (vestibulotoxic), loop diuretics at high doses, benzodiazepines (impair vestibular compensation), antipsychotics. Review the drug list before attributing vertigo to a primary vestibular cause.In this patient: amlodipine at 10 mg can cause orthostatic hypotension — check lying/standing BP before diagnosing BPPV.	Drug-inducedStop culprit

1B — Red flags

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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 or urgent same-day MRI
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

1D — ICE

💭 Ideas

"What do you think might be causing this — do you have any thoughts about what's happening?"

Many patients present convinced they have had a stroke — particularly those with vascular risk factors. Others are certain it is "inner ear." Understanding their model allows the GP to position the examination and explanation appropriately — confirming or addressing the model before explaining the actual diagnosis.

😟 Concerns

"I can imagine this is quite frightening — is there something specific you've been worried this might be?"

The dominant fear in acute severe vertigo is stroke — particularly in middle-aged and older adults with known cardiovascular risk factors. Naming this concern directly ("Are you worried this might be a stroke?") and then explaining the examination and its findings gives the patient the specific reassurance they need rather than generic "everything is fine."

🎯 Expectations

"What were you hoping we might be able to do about this today?"

Many patients with acute vertigo expect an MRI brain scan. Understanding this expectation allows the GP to explain why the HINTS bedside examination is more sensitive than MRI in the first 48 hours of acute vestibular syndrome — a counterintuitive but evidence-based and confidence-building explanation.

1E — Psychosocial context

😰 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 guidelines recommend at least 4 weeks off driving after acute disabling vertigo (Group 1 car licence). 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 formally, the DVLA requires at least 4 weeks off driving after acute disabling vertigo. Let's make sure we keep this under review."

💼 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."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Is the room spinning, or is it more of a lightheaded or unsteady feeling — I'm asking because that changes everything about what might be causing it."

"Any headache when this started? Any double vision, slurred speech, or weakness anywhere?"

"How long does each bout of spinning last — seconds when you move, or is it there all the time?"

"Are you worried this might be a stroke — that's a very natural thing to be concerned about with symptoms like this."

Deductions

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

🔴 Red

Doesn't distinguish vertigo from dizziness; no neurological red flag screen; Dix-Hallpike before history; doesn't ask episode duration; ICE not explored

🟠 Amber

Vertigo confirmed; neurological screen partially done; episode duration asked; vascular risk factors not linked to central exclusion need; ICE partially explored

🟢 Green

Vertigo confirmed as rotational; neurological red flags fully screened; episode duration, triggers, hearing change, recent viral illness, and vascular risk all covered; stroke concern named and addressed; DVLA mentioned

Step 2

Triage Engine — Emergency · Urgent · Routine

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🔴 Emergency

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

🟠 Urgent

Same-Day / 48-Hour Assessment

Rapid assessment

Acute vestibular syndrome — cannot exclude stroke clinicallyIf HINTS equivocal or patient too distressed for reliable HINTS → same-day MRI DWI
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

🟢 Routine

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)Prochlorperazine + prednisolone + vestibular rehabilitation; 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

🎓 SCA Checkpoint — Step 2Tasks

🔴 Red

Diagnoses BPPV without excluding stroke; no HINTS exam; triage decision not linked to named clinical features

🟠 Amber

Red flags screened; triage broadly correct; HINTS not mentioned; reasoning not shared with patient

🟢 Green

Red flags explicitly excluded; HINTS exam planned before Epley; triage decision linked to named features; reasoning shared with patient including stroke concern addressed

Step 3

Do I Need This Examination?

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The HINTS examination is the most important bedside test in acute vestibular syndrome — it is more sensitive than MRI in the first 48 hours for posterior fossa stroke. Dix-Hallpike testing must only be performed AFTER central causes have been clinically excluded or the HINTS exam result is consistent with a peripheral lesion. Never perform Dix-Hallpike as the first examination in a patient with acute vertigo without screening for central features first.

Examination	Why it matters	Finding + action	Mandatory?
HINTS Exam (Head Impulse, Nystagmus type, Test of Skew)	The most important bedside test in acute vestibular syndrome. More sensitive than MRI DWI in the first 48 hours for posterior fossa stroke. Peripheral HINTS (reassuring): abnormal head impulse (catch-up saccade present) + direction-fixed nystagmus + no skew. Central HINTS (stroke): normal head impulse + direction-changing nystagmus + skew deviation.Each component independently contributes to the assessment. A normal head impulse test (no catch-up saccade) in a patient with acute vertigo is a red flag for central pathology — the peripheral vestibular system is not damaged if the vestibulo-ocular reflex is intact.	Central HINTS = 999. Peripheral HINTS = proceed to Dix-Hallpike. Equivocal HINTS in high-risk patient = urgent MRI DWI	YES — first in AVS
Dix-Hallpike test	Diagnostic test for posterior canal BPPV — the patient is moved rapidly from sitting to lying with the head rotated 45° toward the affected side. Positive result: geotropic torsional upbeat nystagmus with 2–5 second latency, lasting under 1 minute, that fatigues on repeat testing.Sensitivity 79%, specificity 75% for posterior canal BPPV. Perform only after central cause has been clinically excluded. If positive, the Epley manoeuvre can be performed immediately in the same clinic visit.	Positive (torsional, fatiguing nystagmus) → BPPV confirmed → Epley manoeuvre. Negative (direction-changing, non-fatiguing, or vertical pure nystagmus) → consider central or atypical canal BPPV	YES — if peripheral HINTS
Romberg test and gait assessment	Romberg positive (falls with eyes closed) indicates absent proprioceptive or vestibular compensation. Gait in peripheral vertigo: cautious, past-pointing to affected side, able to tandem gait with effort. Central ataxia: wide-based, unable to tandem gait, disproportionate severity of ataxia relative to nystagmus.A patient with "vertigo" who cannot walk at all and has severe truncal ataxia has central vertigo until proven otherwise — the degree of ataxia in peripheral vertigo rarely completely prevents walking.	Severe truncal ataxia disproportionate to nystagmus → central pathology → 999 or urgent MRI. Mild to moderate Romberg-positive → peripheral → proceed with vestibular assessment	YES — always in vertigo
BP lying and standing	Excludes postural hypotension as a cause of dizziness — particularly relevant in this patient on amlodipine 10 mg (a significant vasodilator at high dose). A systolic drop ≥20 mmHg with symptoms on standing = orthostatic hypotension, which can be mistaken for or contribute to vestibular symptoms.Never perform Dix-Hallpike in a patient who may have orthostatic hypotension without first excluding it — the position change could precipitate a presyncopal episode during the test.	Systolic drop ≥20 mmHg → orthostatic hypotension → medication review; lying/standing BP protocol; adjust amlodipine dose	YES in this patient
Otoscopy + brief hearing assessment	Identifies middle ear pathology — otitis media, cholesteatoma, or effusion — as a cause of vestibular symptoms. Whisper test or tuning fork test provides basic hearing assessment — unilateral hearing loss + vertigo requires ENT and MRI IAM exclusion of acoustic neuroma or AICA stroke.In this stem: otoscopy is unlikely to find pathology, but it is a necessary examination to complete the vestibular assessment systematically.	Normal → proceed. CSOM or cholesteatoma → ENT. Hearing loss unilateral → MRI IAM or if acute onset + severe vertigo → 999 AICA stroke pathway	Yes — if hearing change

🎓 SCA Checkpoint — Step 3Tasks

🔴 Red

Dix-Hallpike performed before HINTS or neurological screen; HINTS exam not mentioned; lying/standing BP not checked in antihypertensive patient

🟠 Amber

HINTS mentioned; Dix-Hallpike planned after; lying/standing BP not mentioned; gait not assessed; findings not linked to central vs peripheral distinction

🟢 Green

HINTS first and result interpreted; Dix-Hallpike only after peripheral confirmed; lying/standing BP in this antihypertensive patient; gait assessed; all findings explicitly linked to peripheral vs central decision

Step 4

Do I Need This Investigation?

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Investigation	Clinical question it answers	Key result + action
MRI DWI (diffusion-weighted imaging)	The definitive investigation for posterior circulation stroke in vertigo — detects acute ischaemia within hours. However, sensitivity in the first 48 hours is under 80% for posterior fossa — HINTS exam by an experienced clinician is more sensitive. MRI is mandatory if central features are present or HINTS is equivocal. CT is inadequate for posterior fossa lesions (bone artefact).	Acute DWI restriction → ischaemic stroke → stroke pathway. Normal → posterior fossa stroke not excluded if within 48 hours — reimage at 48–72 hours if clinical suspicion remains
CT head	Less sensitive than MRI for posterior fossa pathology but rapidly available for haemorrhage exclusion. Indicated for sudden onset severe headache + vertigo (subarachnoid or cerebellar bleed) when MRI is not immediately available. Not appropriate for ischaemic posterior circulation stroke exclusion.	Cerebellar haematoma → neurosurgery. Normal CT + high suspicion of ischaemia → MRI DWI as next step
Pure-tone audiogram	For recurrent vertigo with associated hearing change — confirms SNHL pattern and severity. Mandatory for Menière's disease workup. Also required for vestibular schwannoma (acoustic neuroma) assessment alongside MRI IAM. Not needed for straightforward first-episode BPPV.	Low-frequency SNHL fluctuating → Menière's pattern. Unilateral SNHL → MRI IAM. Normal → peripheral vestibular cause more likely
Blood tests (FBC, glucose, TFTs)	Anaemia causes lightheadedness often conflated with vertigo. Hypoglycaemia mimics acute vestibular syndrome. Hypothyroidism causes multisensory dizziness. Not required for straightforward acute BPPV but appropriate for first presentation of sustained vertigo without obvious cause.	Anaemia → treat; reassess dizziness. Hypoglycaemia → treat; review medications. Hypothyroidism → treat; dizziness often improves
Lying and standing BP (formal protocol)	Formal 3-minute standing protocol excludes orthostatic hypotension as a cause of dizziness — particularly important in patients on antihypertensives (especially amlodipine at 10 mg). Medication-induced orthostatic hypotension can co-exist with BPPV.	Systolic drop ≥20 mmHg → orthostatic hypotension → medication review; consider amlodipine dose reduction

🎓 SCA Checkpoint — Step 4Tasks

🔴 Red

CT ordered for posterior fossa ischaemia exclusion; MRI not planned for equivocal HINTS; "routine bloods" without clinical rationale

🟠 Amber

MRI planned for high-risk patients; audiogram not considered; investigations not explained to patient

🟢 Green

MRI DWI (not CT) for posterior fossa; audiogram if hearing change; investigations explicitly linked to clinical questions; explains why HINTS is more sensitive than MRI in first 48 hours

Step 5

Reaching a Diagnosis & DDx — Explained in Plain Language

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🗣️ Explaining Vertigo in Plain Language

"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."

A — Diagnosable + Treatable in Primary Care

GP can diagnose and treat

BPPV — Posterior Canal (90% of BPPV)

Positional rotational vertigo <1 minute triggered by rolling over, looking up. Dix-Hallpike positive: torsional upbeat nystagmus, 2–5 sec latency, fatigues on repeat. HINTS peripheral. Treatment: Epley manoeuvre — 85% resolution with one treatment. 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), prednisolone 50 mg × 5 days (shortens course), vestibular rehabilitation. Resolves over 1–6 weeks.

B — Refer to ENT / Specialist

Specialist needed

Menière's Disease

Episodic vertigo (20 min–12 hrs) + unilateral SNHL (fluctuating) + tinnitus + aural fullness. Confirmed by ENT with audiogram. Treatment: betahistine, salt restriction, diuretic, intratympanic treatment in refractory cases. 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.

C — Emergency — Act Now

999 immediately

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.

📊 HINTS Exam Interpretation Guide

Component	Peripheral (reassuring)	Central (red flag → 999)
Head Impulse Test	Abnormal — catch-up saccade visible after rapid head thrust (VOR impaired = peripheral lesion)	Normal — smooth conjugate eye movement (VOR intact = central lesion)
Nystagmus Type	Direction-fixed — nystagmus beats the same direction regardless of gaze direction	Direction-changing — nystagmus changes direction with different gaze positions; or vertical; or purely horizontal without head impulse abnormality
Test of Skew	No vertical skew deviation on cover-uncover test	Skew deviation present — one eye higher than the other on cover-uncover test
Overall interpretation	All 3 peripheral findings = INFARCT unlikely — peripheral cause probable	Any 1 central finding = posterior fossa lesion until excluded by MRI DWI

Step 6

If Referral Is Needed — What the GP Does Before & During

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Condition	Urgency	What GP does before referral	What GP must NOT do
Posterior circulation stroke / central HINTS	999 immediately	HINTS exam result documented. Activate stroke pathway. Note time of symptom onset (thrombolysis window). Record all neurological deficits. Lay patient flat. Start aspirin 300 mg if ischaemic stroke not excluded (unless on anticoagulation).	Do not give antiemetics and "wait and see" in a patient with central HINTS or neurological features. Do not allow a high-vascular-risk patient with unexplained sustained vertigo to leave without being seen by a physician today.
BPPV — confirmed, Epley performed	Routine ENT if fails ×3	Perform Epley manoeuvre in clinic (see 7C). Provide Brandt-Daroff exercise leaflet. Advise no driving until vertigo resolves. Review 2 weeks — if not resolved, repeat Epley. After 3 failed treatments → ENT referral for vestibular physiotherapy or atypical canal assessment.	Do not prescribe long-term prochlorperazine for BPPV — antiemetics impair vestibular compensation and delay recovery. Use only for acute nausea control (maximum 3–5 days).
Vestibular neuritis — confirmed peripheral	Routine vestibular rehab	Prescribe prochlorperazine buccal (short course); prednisolone 50 mg × 5 days (shortens acute phase); refer vestibular rehabilitation physiotherapy; advise falls precautions; DVLA advice; review 1 week.	Do not prescribe antiemetics for more than 5 days — they suppress vestibular compensation and significantly prolong the recovery period. Vestibular rehabilitation is the cornerstone of treatment, not medication.
Menière's disease (suspected)	4-week ENT	Audiogram; start low-salt diet advice; betahistine 16 mg TDS if ENT has confirmed diagnosis; prochlorperazine for acute attacks only; DVLA advice (not to drive during attacks). Refer ENT for diagnostic confirmation and specialist management.	Do not start betahistine before ENT confirms Menière's diagnosis — the triad must be confirmed on audiometry and clinical assessment before initiating long-term treatment.

Step 7

Management — Expectation · Goals · Epley · Drug Cards · Psychosocial · Follow-Up · Safety-Netting

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7A — Address the patient's expectation first

🤝

The patient with acute vertigo is frightened and expects either a brain scan or to be told there is nothing wrong. Address both.

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."

7C — The Epley Manoeuvre (BPPV treatment) — teach and perform

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Epley Manoeuvre

85% resolution with single treatment — perform in clinic

Mechanism

The Epley manoeuvre repositions otoliths (calcium carbonate crystals) displaced from the utricle back into the posterior semicircular canal through a series of sequential head positions that use gravity to guide the crystals. Each position is held for 90 seconds to allow the crystals to settle.

Steps

1. Dix-Hallpike to affected side (hold 90 sec). 2. Rotate head 90° to opposite side (hold 90 sec). 3. Roll body toward unaffected side, head now facing floor (hold 90 sec). 4. Sit patient up slowly. 5. Head returns to midline. Keep upright for 20 min post-procedure.

85% resolution in single treatment; repeat 3 times before referring to ENT

🏃

Brandt-Daroff Exercises

Home self-management — twice daily until symptoms resolve

Mechanism

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.

Practical

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.

Accelerates recovery and reduces recurrence when combined with Epley

🧘

Vestibular Rehabilitation

Referral to vestibular physiotherapy for vestibular neuritis

Mechanism

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.

Practical

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.

Vestibular rehabilitation reduces chronic dizziness disability by 50% — more effective than medication for vestibular neuritis

🚗

DVLA Advice

At least 4 weeks off driving — acute disabling vertigo

Legal requirement

DVLA Group 1 (car): must not drive while experiencing disabling vertigo. Can resume when symptoms are controlled and unlikely to cause sudden disabling recurrence — minimum 4 weeks from the acute episode. Group 2 (HGV/bus): specialist assessment required before return to driving.

Practical

Advise explicitly: "You should not drive until the vertigo has completely resolved and you have been free of significant symptoms for at least 4 weeks." Document this advice in the clinical notes. Notify the patient that they must inform the DVLA if episodes are recurrent and disabling.

DVLA advice is mandatory and must be documented — failure to advise is a medicolegal risk

🏠

Falls Prevention

Acute phase — home safety assessment

Practical

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.

Falls prevention during acute vestibular episode reduces serious injury risk in older adults significantly

💊

Antiemetics — Short Course Only

Maximum 3–5 days — longer impairs vestibular compensation

Critical principle

Prochlorperazine provides acute symptom relief for nausea and vertigo — but if continued beyond 5 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.

Stop antiemetics within 5 days — vestibular rehabilitation, not medication, is the long-term solution

7F — Drug reference cards: vertigo pharmacological management

Prochlorperazine (Stemetil)

Buccal 3 mg BD or oral 5 mg TDS — acute symptom control in vestibular neuritis / BPPV

Acute vertigo3–5 mg TDS · max 5 days

✓ Use when

Acute nausea and vomiting preventing oral intake or cooperation with vestibular examination

Short-term symptomatic relief while vestibular compensation begins

Buccal (Buccastem 3 mg) preferred if vomiting prevents oral tablets

✗ Time-limit strictly

Maximum 5 days — beyond this duration, suppresses vestibular compensation and prolongs disability

Do NOT prescribe long-term "for dizziness" — this is a very common and harmful prescribing error

Elderly — increased risk of extrapyramidal side effects; consider a lower dose or alternative antiemetic

💬 Counselling

"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 5 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 5 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 5 days — longer than that actually slows recovery."

Prednisolone — Vestibular Neuritis

50 mg OD × 5 days then taper — shortens acute phase; NICE CKS evidence-based

Vestibular neuritis50 mg OD × 5 days

✓ Initiate when

Vestibular neuritis confirmed (sustained vertigo days, post-viral, peripheral HINTS)

Best started within 72 hours of onset — reduces inflammatory damage to the vestibular nerve

Evidence: shortens acute phase; improves final vestibular function recovery

✗ Caution

Diabetes — monitor blood glucose closely during course

Taper if course over 7 days; 5-day course at 50 mg can stop abruptly

💬 Counselling

"This short course of steroid tablets helps reduce the inflammation in the balance nerve — it tends to shorten how long the acute spinning phase lasts and improves how much function your balance system recovers. Take it with food for 5 days."

Prednisolone for vestibular neuritis is a NICE CKS-recommended evidence-based treatment that is often omitted in GP consultations. Prescribing it and explaining its mechanism (reducing vestibular nerve inflammation) scores in the Tasks domain. Pairing it with the explicit statement "maximum 5 days of prochlorperazine" demonstrates systematic management thinking.

Betahistine — Menière's Disease

Serc 16 mg TDS — only after ENT confirms Menière's diagnosis

Menière's only16 mg TDS × ≥6 months

✓ Only when Menière's confirmed

Menière's disease confirmed by ENT with audiogram-supported diagnosis

Minimum 6-month trial before assessing response

Combined with low-salt diet (<1.5 g sodium/day) for best effect

✗ Do not use empirically

Do not prescribe betahistine for any acute vertigo without ENT confirming Menière's

Asthma — histamine pathway; caution; peptic ulcer risk

💬 Counselling

"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; the benefit builds up over weeks and months. Low-salt diet alongside it makes it significantly more effective."

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.

Aspirin 300 mg (if ischaemic stroke suspected)

Single loading dose — while awaiting hospital admission for posterior circulation stroke

Stroke emergency300 mg stat

✓ Give when

Ischaemic stroke clinically suspected and NOT on anticoagulation already

Haemorrhage excluded (CT head) — but in practice, give while awaiting 999 if ischaemic features

✗ Do NOT give if

Already on anticoagulation — do not add aspirin; risk of haemorrhage

Haemorrhage not excluded and strong suspicion of bleed — withhold until CT result

💬 Counselling

"I'm giving you a single aspirin tablet while we wait for the ambulance — this helps prevent any clot from extending. The hospital team will decide on further treatment when they see you."

Aspirin 300 mg for suspected ischaemic stroke is a NICE-recommended emergency measure while awaiting hospitalisation. Remembering to give this while calling 999 demonstrates comprehensive emergency management and scores in Tasks.

7G — Psychosocial impact: fear, avoidance, and return to function

🫂

Living with vertigo — acute and chronic impact on daily life

😰

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."

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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. The DVLA advice (minimum 4 weeks) 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."

7H — Follow-up

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; continue prednisolone if within window.

Symptom reviewDVLA check

4–6 Weeks — Recovery assessment + return to driving

Review vestibular neuritis recovery; assess readiness to return to driving (minimum 4 weeks from onset if symptoms have resolved); vestibular rehab progress; PHQ-9 if anxiety or chronic dizziness developing; fit note review for return to work.

Driving returnPHQ-9

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.

PPPD assessmentAudiogram if hearing change

7J — Safety-netting

⚠ Three scenario-specific phrases

🎓 SCA Checkpoint — Step 7 (Final)TasksRelating to OthersGlobal Skills

Closing the consultation

"To summarise: I've done the eye examination to check for a brain cause — that looked reassuring. The hearing and balance test suggests this is the crystal type of vertigo, and I'm going to treat it now with the head repositioning sequence."

"The nausea tablet is for 5 days only — please stop it after that even if you're still dizzy, because longer than that slows recovery."

"If you develop any headache, double vision, or weakness alongside the dizziness — call 999 immediately. And you shouldn't drive for at least 4 weeks."

"Is there anything you'd like to ask before I do the treatment?"

Deductions — closing

Prescribing long-term prochlorperazine without the 5-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

Tasks — full criteria

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 5-day maximum
DVLA driving advice (4 weeks minimum) given and documented

Relating to Others — full criteria

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

🔴 Red

Epley before HINTS; long-term prochlorperazine; no DVLA; no neurological safety-net; stroke concern not addressed; no Epley offered for confirmed BPPV

🟠 Amber

HINTS done; Epley performed; prochlorperazine 5-day limit not stated; DVLA mentioned briefly; stroke concern not named before examination

🟢 Green

HINTS first then Dix-Hallpike; Epley in clinic; prochlorperazine 5-day limit explicitly stated; DVLA documented; neurological red flag safety-net given; stroke concern named and addressed empathetically; falls risk addressed

"This is terrifying — the room won't stop spinning and I keep being sick. I'm scared something's happened to my brain."

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 the 85% success rate is explained
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 5-day limit if the recovery rationale is explained clearly

"Are you sure this isn't a stroke? Shouldn't I be going to hospital?"

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 5-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.

🏥

Clinic Quick Reference

Vertigo — Clinical Decision Framework

NICE CKS Vertigo 2022 · BPPV Clinical Guidelines · HINTS Examination Protocol

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🚦 1 — Triage + HINTS Guide

Acute vertigo → neurological screen first → HINTS exam → Dix-Hallpike only if peripheral HINTS

🔴 999 — Central

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)

999 + stroke pathway immediately

🟢 Peripheral → Primary Care

Peripheral HINTS (catch-up saccade, direction-fixed Nystagmus, no Skew)
BPPV: Dix-Hallpike + Epley in clinic
Vestibular neuritis: prednisolone + rehab

Epley / prednisolone / vestibular rehab

HINTS Interpretation (3 components)

Peripheral (all 3):
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 ✗

📊 2 — Key Numbers

5 days

Prochlorperazine maximum — longer impairs vestibular compensation

85%

BPPV resolution after single Epley manoeuvre

90 sec

Hold time at each Epley position

4 weeks

DVLA minimum off driving — acute disabling vertigo

48 hrs

Window when HINTS > MRI sensitivity for posterior fossa stroke

79%

Dix-Hallpike sensitivity for BPPV

⚠ 3 — Safety Netting

🎓

SCA Quick Reference

SCA Consultation Blueprint

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🕐 12-Minute Flow

0–2 min

Open + Type of Dizziness

"That sounds really frightening. Can you describe what the dizziness is like — is the room spinning, or is it more of a lightheaded feeling?"

TasksRelating to Others

✗ Not confirming rotational vertigo first · ✗ No empathy for acute distress

2–4 min

Neurological Red Flag Screen

"Any headache when this started? Double vision? Slurred speech? Weakness or numbness anywhere? How long does each bout last?"

Tasks

✗ Performing positional test before this screen · ✗ Missing episode duration question

4–7 min

ICE + HINTS Exam

"Are you worried this might be a stroke? I'm going to do a specific eye test now — this is actually more sensitive for brain problems than an MRI in the first 48 hours."

TasksRelating to Others

✗ Stroke concern not named · ✗ HINTS not performed · ✗ Dix-Hallpike before HINTS

7–10 min

Dix-Hallpike + Epley

"The eye test is reassuring — it doesn't suggest a brain problem. Now I'm going to do the specific position test for the crystal type, and if it's positive, I can treat it straight away."

TasksRelating to Others

✗ No Epley offered after positive Dix-Hallpike · ✗ Diagnosis without Dix-Hallpike

10–12 min

Safety-Net + DVLA + Close

"The prochlorperazine is for 5 days only — stopping it after that actually helps you recover faster. No driving for at least 4 weeks. If you get a headache or weakness with the dizziness — 999."

TasksRelating to OthersGlobal Skills

✗ Long-term prochlorperazine · ✗ No DVLA · ✗ No neurological red flag safety-net · ✗ No closing question

🚫 8 Danger Zones

✗

Dix-Hallpike before neurological screen or HINTS
→ Neurological red flags → HINTS → Dix-Hallpike. This sequence is non-negotiable.

✗

Prescribing prochlorperazine without the 5-day maximum
→ "This is for 5 days only — longer than that actually slows your recovery by interfering with the brain's ability to adapt"

✗

Not naming the stroke concern before examining
→ "Are you worried this might be a stroke? That's a very understandable thing to be concerned about with these symptoms."

✗

Not offering the Epley manoeuvre in clinic for confirmed BPPV
→ "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"

✗

Not giving DVLA advice
→ "You should not drive for at least 4 weeks — and that advice needs to be documented in your notes today"

✗

Diagnosing BPPV without Dix-Hallpike test
→ The diagnosis of BPPV requires a positive Dix-Hallpike. "I think this might be BPPV — let me do the specific test to confirm it"

✗

Not giving a neurological red flag safety-net
→ "If the vertigo returns and you have any headache, double vision, or weakness — 999 immediately"

✗

Not ordering MRI DWI (ordering CT instead) when central features are present
→ "CT cannot see the posterior fossa clearly — MRI DWI is the test we need for this area of the brain"

Vertigo

Red Flags — posterior circulation stroke must be excluded first

😰 Fear and Acute Distress

🚗 Driving — Acute Safety Restriction

💼 Work and Daily Function

😔 Chronic Vertigo and Anxiety

🤢 Nausea and Wellbeing

🏠 Falls Risk and Safety

999 — Stroke Pathway

Same-Day / 48-Hour Assessment

Primary Care Management

BPPV — Posterior Canal (90% of BPPV)

Vestibular Neuritis

Menière's Disease

BPPV — Horizontal or Anterior Canal (Atypical)

Vestibular Migraine

Posterior Circulation Stroke / TIA

Cerebellar Haemorrhage

Validate

Explain

Offer

Fear of Recurrence

Driving and Occupation

Chronic Dizziness and Functional Disorder

Falls and Home Safety

2 Weeks — BPPV response to Epley

4–6 Weeks — Recovery assessment + return to driving

3 Months — If symptoms persist

⚠ Three scenario-specific phrases

🎭 Patient actor brief — click to practise

Who you are

Hidden concern

Symptoms if asked

Responses and challenges