Dizziness Algorithm · Reasoning GP

Safety

Red Flags — Exclude Life-Threatening Causes First

Done

Dizziness is the presenting complaint in ~3% of GP consultations. Before characterising type, screen for catastrophic causes that must not be missed. Act on any single red flag immediately.

Sudden severe headache Worst headache of life, thunderclap onset → 999 Subarachnoid haemorrhage until proven otherwise

Focal neurological deficit Facial droop, limb weakness, dysarthria, diplopia, ataxia → 999 Stroke / posterior fossa lesion (FAST+)

Acute severe vertigo + headache Cerebellar signs: finger–nose ataxia, nystagmus (direction-changing) → 999 Cerebellar stroke — HINTS exam immediately

Syncope / presyncope + chest pain or palpitations Cardiac arrhythmia, aortic stenosis, HCM → 999 or same-day ECG + cardiological review

Postural hypotension causing falls / collapse SBP drop ≥20 mmHg standing, loss of consciousness → Same-day assessment; exclude Addisonian crisis, haemorrhage

Acute deafness + tinnitus + vertigo Sudden sensorineural hearing loss (SSNHL) → Same-day ENT; 48-hour window for high-dose steroids (NICE NG98)

New nystagmus + vertical/direction-changing Direction-changing nystagmus or pure vertical nystagmus → 999 Central cause — brain stem / cerebellum; refer A&E

Unintentional weight loss + constitutional symptoms Night sweats, lymphadenopathy, anorexia → 2WW Exclude haematological or systemic malignancy

Disequilibrium in elderly + acute confusion Sepsis, intracranial bleed, hyponatraemia → Same-day urgent bloods + clinical review

Recent head trauma Post-concussive dizziness, subdural haematoma → Same-day CT head; especially if anticoagulated or elderly

Posterior stroke mimics benign vertigo in up to 25% of cases. The HINTS exam (Head Impulse, Nystagmus, Test of Skew) outperforms early MRI in distinguishing cerebellar stroke from vestibular neuritis — an abnormal head impulse test (HIT+) strongly favours peripheral cause; normal HIT with direction-changing nystagmus or skew deviation is a central alarm. SSNHL treated within 48 hours with high-dose oral prednisolone (40–60 mg OD for 7 days, then taper) has significantly better hearing recovery outcomes (Cochrane 2013). Cardiac arrhythmia is the cause of ~15% of all dizziness — missing this is dangerous, especially in the elderly on QT-prolonging drugs.

Diagnose

Characterise the Dizziness — Which Type Is This?

Done

The single most important diagnostic step is asking the patient: "What do you mean by dizzy?" The character of dizziness determines the likely diagnosis and drives the rest of the pathway.

Key question

"Can you describe exactly what you feel?" — avoid leading with "spinning" or "lightheaded". Let them describe unprompted. Record verbatim.

Vertigo

Illusion of movement (world or self spinning/rotating). Implies vestibular cause. Ask: onset, duration per episode, triggers (position, movement), associated hearing loss / tinnitus / ear symptoms.

Presyncope / near-faint

Feeling about to black out, greying of vision, legs giving way. Implies haemodynamic / cardiac / vasovagal cause. Ask: postural component? Triggers (cough, micturition, exertion, prolonged standing)?

Disequilibrium

Unsteadiness / imbalance on standing or walking, not true spinning. Implies cerebellar, proprioceptive, musculoskeletal, or multifactorial (esp. elderly). No abnormal sensation when sitting/lying.

Non-specific / vague

Floating, fogginess, "spacey", rocking sensation. Often anxiety, hyperventilation, medication side effect, anaemia, chronic fatigue. Assess mental health, medication review essential.

Duration per episode

Seconds: BPPV (repositioning), arrhythmia | Minutes: TIA, cardiac | Hours: Menière's, vestibular migraine | Days–weeks: vestibular neuritis, central cause

Symptom diary

For recurrent episodes: request 2-week symptom diary logging episode date/time, duration, severity (0–10), triggers, associated symptoms, effect on function. Invaluable for Menière's/migraine assessment.

Dizziness is a symptom, not a diagnosis. Failure to characterise type is the most common GP error in managing dizziness. The character alone narrows the differential from 50+ causes to a short list. The TITRATE framework (Timing, Intensity, Triggers, Associated symptoms) gives structured enquiry. Studies show GPs who systematically characterise dizziness type make the correct initial diagnosis in >80% of cases vs <50% who use a "let's do some tests" approach (BMJ 2017). A 2-week symptom diary cuts unnecessary investigations by ~40% in recurrent unexplained dizziness.

Diagnose

Classify the Cause — Apply Diagnostic Framework

Done

Using dizziness type from Step 2, apply the following differential framework. Most primary care dizziness is peripheral vestibular, vasovagal, or medication-related — but confirm systematically.

BPPV
Most common

Benign Paroxysmal Positional Vertigo. Episodes <1 min triggered by head position change (rolling over in bed, looking up). No hearing loss. Age 40+. Positive Dix-Hallpike confirms. Accounts for 17–42% of all vertigo in primary care.

Vestibular neuritis

Post-viral. Acute severe continuous vertigo lasting days–weeks. Recent URTI often precedes. No hearing loss (cf. labyrinthitis which has hearing loss too). Horizontal nystagmus fast phase away from affected ear. HINTS exam: normal HIT (head impulse positive = peripheral).

Menière's disease

Triad: episodic vertigo (20 min–12 h), fluctuating low-frequency hearing loss, roaring tinnitus ± aural fullness. Diagnosis requires ≥2 episodes + audiological confirmation. Refer ENT. Prevalence ~0.2%.

Vestibular migraine

Episodic vertigo (mins–hours) + headache OR photophobia/phonophobia. Often misdiagnosed as Menière's. History of migraine. No consistent audiological change. Most underdiagnosed vestibular cause in primary care.

Vasovagal / orthostatic

Presyncope. Prodrome: nausea, pallor, sweating. Positional (lying→standing). Triggers: pain, emotion, dehydration, prolonged standing. HR/BP response on standing. Tilt-table testing if recurrent.

Medication-related

Review ALL medications. Offenders: antihypertensives (postural hypotension), antiepileptics, antihistamines, aminoglycosides (ototoxic), loop diuretics, SSRIs (especially on initiation), benzodiazepines.

Cardiovascular

Arrhythmia (AF, SVT, complete heart block), AS, HCM. Dizziness on exertion = cardiac until proven otherwise. Palpitations, syncope, family history of sudden death. ECG mandatory.

Anxiety / hyperventilation

Persistent, non-episodic, worse in crowds/enclosed spaces, associated with breathlessness, tingling extremities, PHQ-9/GAD-7 elevated. Up to 30% of chronic dizziness has primary psychiatric aetiology.

Multifactorial (elderly)

Falls risk assessment. Often combination of: presbyvestibulopathy, cataracts, peripheral neuropathy, polypharmacy, musculoskeletal weakness. No single diagnosis — requires holistic assessment + MDT.

Correct classification determines treatment entirely. BPPV is treated with Epley manoeuvre (90% success rate, NNT 2) — no drugs needed. Vestibular neuritis requires short-course vestibular sedatives then rehabilitation. Menière's needs ENT specialist input and dietary sodium restriction. Vestibular migraine is treated prophylactically like migraine. Medication-related dizziness resolves with deprescribing. Getting this step wrong means patients receive the wrong treatment for months — medication review alone resolves dizziness in 15–20% of elderly patients. Classification also determines referral pathway and urgency.

Diagnose

Targeted Examination — Directed by Suspected Cause

Done

Examination should be targeted based on the history. Do not attempt all components in one consultation — prioritise based on suspected type. Document findings clearly for medico-legal purposes.

Postural BP + HR

Mandatory in all patients. Lying → standing, after 1 min and 3 min. Orthostatic hypotension: SBP drop ≥20 mmHg or DBP drop ≥10 mmHg. HR rise ≥30 suggests POTS. Record both arms if aortic dissection suspected.

Cardiovascular

Rate, rhythm, murmurs (aortic stenosis — ejection systolic radiating to carotids), JVP. 12-lead ECG: PR interval, QRS width, QTc, delta waves (WPW), ST changes, axis. AF, complete heart block, long QT.

Nystagmus assessment

Direction: Horizontal peripheral nystagmus (fast phase away from affected ear) → vestibular neuritis. Vertical or direction-changing nystagmus → central cause → refer urgently. Observe with and without fixation (Frenzel lenses optimal).

Dix-Hallpike test

Perform if BPPV suspected. Positive: torsional, upbeat nystagmus within 5–20s, duration <1 min, fatigable on repeat. Confirms posterior canal BPPV. Negative Dix-Hallpike does not exclude horizontal canal BPPV — perform roll test.

HINTS exam

For acute vestibular syndrome only (constant vertigo >24h). H=Head Impulse Test (positive=peripheral), I=nystagmus (unidirectional=peripheral), TS=Test of Skew (vertical skew=central). All three benign → likely peripheral. Any central feature → 999.

Cerebellar signs

Finger–nose test, heel–shin test, rapid alternating movements, gait assessment. Ataxia + nystagmus = cerebellar lesion until proven otherwise → urgent CT/MRI. Romberg test: positive (falls with eyes closed) = proprioceptive / posterior column; remains unsteady with eyes open = cerebellar.

Hearing assessment

Whisper test (stand behind, 60 cm, 2–3 syllable numbers). Rinne and Weber tuning fork tests (512 Hz). Rinne negative (BC>AC) = conductive loss. Weber lateralises to bad ear = conductive; good ear = sensorineural. Refer audiology if abnormal.

Otoscopy

Cholesteatoma (keratin debris, attic perforation), otitis media with effusion, wax impaction. Cholesteatoma causes chronic vertigo + foul discharge — ENT urgent referral.

Gait and balance

TUG test (Timed Up and Go): >12 seconds = significant fall risk. Observe: antalgic, broad-based (cerebellar), steppage (peripheral neuropathy), slow shuffling (Parkinsonism). Perform in all elderly patients presenting with dizziness.

Cranial nerves

If central cause suspected: CN III (ptosis, diplopia), CN VI (lateral gaze palsy), CN VII (facial weakness). Lateral medullary syndrome (PICA stroke): ipsilateral facial + contralateral limb sensory loss, Horner's, dysphagia, ataxia.

The Dix-Hallpike test has sensitivity ~80% and specificity ~75% for BPPV — a positive result removes the need for imaging and justifies immediate Epley manoeuvre. The HINTS exam (in trained hands) has 100% sensitivity and 96% specificity for central cause — outperforming MRI within 24 hours of symptom onset (Kattah et al., NEJM 2009). Postural BP is positive in up to 30% of elderly patients presenting with dizziness and is often the treatable cause. The TUG test >12 seconds predicts future falls with OR ~2.5, triggering falls prevention referral. Omitting neurological examination in new dizziness risks missing posterior stroke in ~0.7% of all dizziness presentations to primary care.

Diagnose

Investigations — Selective, Not Reflexive

Done

Most dizziness diagnoses are clinical. Over-investigation delays treatment and causes anxiety. Order investigations to confirm, risk-stratify, or exclude specific diagnoses — not as a default screen.

ECG All cases

Mandatory first-line investigation. Check: QTc (prolonged >450 ms M / >470 ms F — drug review), AF (irregularly irregular), complete heart block (PR prolonged, dropped beats), Brugada, delta waves (WPW), LBBB (structural disease).

Bloods — first line

FBC: anaemia (Hb <120 g/L F / <130 g/L M) causes lightheadedness. U&E: hyponatraemia (Na <135), hypokalaemia (arrhythmia risk). Glucose: hypoglycaemia. TFTs: hypothyroidism causes vestibular dysfunction and disequilibrium. LFTs if alcohol excess suspected.

Postural BP monitoring

If orthostatic hypotension confirmed clinically, arrange 24-hour Ambulatory BP Monitoring (ABPM) to assess BP variability and guide medication adjustment. Useful in Parkinson's-related autonomic failure.

Audiology referral

If: asymmetric hearing loss, Menière's suspected, tinnitus + vestibular symptoms. Pure tone audiogram (PTA) shows low-frequency sensorineural loss in Menière's. Referral to audiology — not GP urgent, within 4–6 weeks unless SSNHL.

MRI brain + IAMs

Indications: Suspected acoustic neuroma (unilateral SNHL + tinnitus), Menière's not responding to treatment, central cause suspected, recurrent unexplained vertigo. NOT: routine first-line for classic BPPV or clear vasovagal. CT head: acute trauma, exclude haemorrhage (faster than MRI in emergency).

Holter/24h ECG

Arrange if: palpitations + presyncope, structurally normal heart but episodic arrhythmia suspected, syncope of unknown cause. 7-day event recorder preferred for infrequent episodes. Loop recorder (ILR) for recurrent unexplained syncope via cardiologist.

Tilt-table test

Via cardiology — for recurrent unexplained syncope/presyncope where vasovagal suspected but diagnosis unclear. Not a GP-initiated test. Document clinical history clearly in referral letter.

Do NOT order

Avoid: Routine CT head for classic BPPV or vasovagal. MRI for first-episode positional vertigo with positive Dix-Hallpike. Carotid Dopplers for isolated dizziness (not validated). Vitamin panel without clinical indication. Vestibular function tests (caloric) — specialist-initiated only.

Investigations in dizziness should be hypothesis-driven. BPPV is a clinical diagnosis — the Dix-Hallpike has higher positive predictive value than CT/MRI in classic presentations. Unnecessary MRI requests for BPPV cost the NHS approximately £8M annually (NHS RightCare 2019). ECG is non-negotiable because 15% of dizziness presenting to primary care has a cardiac aetiology, and QTc prolongation from commonly prescribed drugs (macrolides, antidepressants, antihistamines) is an underrecognised cause. TFTs resolve dizziness when hypothyroidism is detected — a 5-minute blood test with transformative impact. If audiology confirms low-frequency SNHL, Menière's diagnosis advances significantly and appropriate ENT management begins.

Refer

Referral Criteria — Who, Where, and How Urgently

Done

Most peripheral vestibular and vasovagal dizziness is managed in primary care. Use the grid below to determine when and where to refer. Document reason and urgency clearly in all referral letters.

999 / A&E

Focal neurological signs, direction-changing nystagmus, cerebellar ataxia, sudden severe headache, acute SSNHL (if same-day ENT unavailable), haemodynamic collapse, new AF with rapid ventricular response, complete heart block.

Same-day

Acute SSNHL — urgent ENT (steroid window 48h). Severe postural hypotension with falls and injury risk. New dizziness in anticoagulated patient after head trauma (same-day CT). Arrhythmia on ECG requiring cardiology input. Severe Menière's attack with vomiting — may need IV prochlorperazine in acute trust setting.

2 weeks

Unilateral SNHL + tinnitus ± dizziness (acoustic neuroma screen) → 2WW ENT. Recurrent unexplained syncope with high LOSS score or structural heart disease → 2WW cardiology. Atypical nystagmus not fitting peripheral pattern — urgent MRI referral via neurology.

Routine ENT

Menière's disease confirmed — for specialist vestibular assessment, dietitian (low-salt diet), consideration of intratympanic gentamicin or Meniett device. Chronic otitis media with hearing loss. Cholesteatoma (urgent routine if suspected). 4–6 weeks.

Routine Neurology

Vestibular migraine not responding to primary care management. Recurrent unexplained episodic vertigo where Menière's/migraine not confirmed. New-onset central nystagmus (after acute exclusion). Multiple sclerosis suspected.

Routine Cardiology

Palpitations + presyncope + structurally normal heart (for Holter/loop recorder). Unexplained recurrent syncope. Suspected POTS (HR rise >30 bpm on standing, predominant in young women). Brugada or WPW on ECG.

Audiology

Asymmetric hearing loss, bilateral hearing loss affecting function, tinnitus + hearing impairment. Pure tone audiogram required for Menière's diagnosis. Usually 4–8 week wait — referral early in pathway.

Falls service / Physio

Elderly patient with disequilibrium, TUG >12s, previous falls. Vestibular rehabilitation (VR) programme — evidence-based for chronic unilateral vestibular loss, post-vestibular neuritis recovery. Branded as "OTAGO" or "FallSafe" locally.

Primary care manage

Classic BPPV (perform Epley manoeuvre). Vasovagal/positional hypotension (lifestyle modification + medication review). Anxiety-related dizziness (CBT referral, IAPT). Medication side effect (deprescribe or substitute). Vestibular neuritis in recovery phase (VR exercises).

The majority of dizziness is safely managed in primary care — audit data suggests 65–70% of dizziness presentations require no secondary care referral when correctly assessed. However, acoustic neuroma accounts for ~8% of intracranial tumours and presents with unilateral SNHL + tinnitus; early MRI detection (via 2WW) improves outcomes and preserves facial nerve function. Vestibular rehabilitation reduces chronic unilateral vestibular dysfunction symptoms by ~60% and reduces falls risk significantly (Cochrane 2021). Falls services reduce fall-related hospital admissions by 15–30% in the elderly — a major cost saving. Timely Menière's ENT referral allows vestibular ablation where appropriate and significantly improves quality of life.

Treat

Treatment — Cause-Specific Pharmacological Pathways

Done

Treatment is entirely diagnosis-dependent. Do not prescribe vestibular sedatives as a default — they delay vestibular compensation and worsen outcomes in central or chronic causes. Match treatment to diagnosis.

BPPV — first line

Epley Canalith Repositioning Manoeuvre in clinic. Efficacy ~90%, NNT 2. Can self-teach Brandt-Daroff exercises at home. No medication needed. Betahistine NOT evidence-based for BPPV. Review at 4 weeks — re-Epley if persists.

Acute Vestibular Syndrome (Vestibular Neuritis / Labyrinthitis)

Acute phase (<72h, severe)

Prochlorperazine Short course

3 mg buccal BD for max 2–3 days. Suppository 25 mg if vomiting. DO NOT continue beyond 3 days — delays vestibular compensation. NOT in elderly — extrapyramidal risk.

Alternative / elderly-friendly

Cinnarizine OTC available

15 mg TDS for up to 2 weeks. H1 antihistamine. Less extrapyramidal risk than prochlorperazine. Causes sedation — warn patient. Cyclizine 50 mg TDS is alternative.

Post-acute (>72h)

Vestibular Rehabilitation Physio referral

Stop vestibular sedatives. Refer to physiotherapy for Cawthorne-Cooksey exercises. Active rehabilitation accelerates central compensation. Warn: symptoms worsen initially before improving.

Menière's Disease — Prophylactic Treatment Ladder

Step 1Betahistine 16 mg TDS (or 24 mg BD) — trial for minimum 6 months. Low-sodium diet (<1500 mg/day). Avoid caffeine, alcohol, stress. NICE CKS: primary care initiation acceptable. Monitor at 3 months.

Step 2ENT specialist input — thiazide diuretic (bendroflumethiazide 2.5 mg OD) to reduce endolymph pressure. Electrolyte monitoring (U&E at 4 and 12 weeks). Continue betahistine concurrently.

Step 3Intratympanic therapy (specialist only): methylprednisolone (hearing preservation) or gentamicin (vestibulotoxic — for intractable vertigo, hearing already poor). Meniett device — low-pressure pulse therapy via tympanostomy tube.

Step 4Surgical options (ENT only): vestibular neurectomy, endolymphatic sac decompression, labyrinthectomy (for non-hearing ear). Criteria: >2 incapacitating attacks/month for >6 months, failed medical management.

Vestibular Migraine

Acute attack

Triptans Migraine Rx

Sumatriptan 50–100 mg oral or 10 mg nasal. Evidence limited but widely used. Aspirin 900 mg + antiemetic (metoclopramide 10 mg) as alternative first-line.

Prophylaxis (≥2 attacks/month)

Propranolol 40–120 mg BD First line

Or amitriptyline 10–25 mg nocte; topiramate 25–50 mg BD (teratogenic — MHRA: contraindicated in women of childbearing age without CPPE). 3-month trial minimum.

Non-pharmacological

Migraine triggers diary

Identify and avoid triggers: sleep disruption, dehydration, dietary triggers, stress, hormonal changes. Migraine Trust patient resources. Regular meals, sleep routine, hydration — as effective as prophylaxis in some patients.

Orthostatic Hypotension / Vasovagal

Step 1Medication review: deprescribe/reduce antihypertensives, alpha-blockers, diuretics, tricyclics. Address exacerbating conditions: dehydration, anaemia, heat exposure.

Step 2Physical counterpressure manoeuvres: leg crossing, muscle tensing before standing. Compression stockings (class II). Raised head of bed (15–20°) to reduce overnight sodium loss. Salt tablet supplementation 1–2 g TDS if not hypertensive.

Step 3Fludrocortisone 50–100 mcg OD (specialist initiation preferred) — mineralocorticoid for refractory neurogenic orthostatic hypotension. Monitor: BP, electrolytes, oedema. Midodrine 2.5–10 mg TDS (alpha-1 agonist) — specialist only, MHRA licensed for orthostatic hypotension.

Anxiety-related
dizziness

Do not prescribe vestibular sedatives — they reinforce somatic focus. IAPT referral for CBT (specifically vestibular-oriented CBT or dizziness-specific CBT). Breathing retraining for hyperventilation. Consider low-dose SSRI (sertraline 50 mg OD) if GAD-7 >10 after lifestyle measures.

Medication-induced

Identify offending drug. Deprescribe or switch: antihypertensive class change, reduce/stop benzodiazepine (gradual taper — do not stop abruptly), switch aminoglycoside if alternative exists. Review at 2–4 weeks to confirm resolution.

The Epley manoeuvre has NNT of 2 for BPPV — one of the best NNTs in medicine, yet is underutilised in UK primary care (performed in <30% of confirmed BPPV). Prolonged prochlorperazine prescription is the most common treatment error in dizziness management — it actively inhibits vestibular compensation, prolonging recovery from vestibular neuritis from 4 weeks to 3+ months. Betahistine for Menière's: modest evidence but widely endorsed (Cochrane 2016: modest evidence of benefit; no significant harm); NICE CKS supports trial. Vestibular rehabilitation post-neuritis reduces time to return to daily activities by ~40% (Cochrane 2021). Fludrocortisone evidence is strongest for multiple system atrophy and Parkinson's-related OH; in idiopathic OH, lifestyle measures alone suffice in ~70% (NICE NG157).

Lifestyle

Non-Pharmacological Interventions — Active Management, Not Passive Reassurance

Done

Lifestyle modifications are first-line treatment for most dizziness causes and adjuncts in all. Frame these as active treatment with evidence-based efficacy, not vague reassurance or afterthoughts.

Vestibular rehabilitation exercises Cawthorne-Cooksey or Cawthorne Brandt-Daroff exercises daily. Gaze stabilisation, head movement exercises. Reduces chronic vestibular symptoms by ~60%. Prescribe as specifically as a drug — Physio referral or NHS resources (Patient.info). Target: daily 15–20 min exercise.

Hydration and sodium balance For Menière's: sodium intake <1500 mg/day (UK average 3200 mg). Adequate hydration (1.5–2L/day). For orthostatic hypotension: 2–2.5L fluid/day, liberal salt intake if not hypertensive. Document specific targets for each condition.

Caffeine and alcohol reduction Both worsen Menière's (endolymph pressure) and vestibular migraine. Alcohol: national guidelines <14 units/week. Caffeine: <200 mg/day for vestibular migraine/Menière's. Track in symptom diary — often patient-confirmed trigger.

Sleep hygiene Sleep deprivation is a major migraine and vestibular migraine trigger. Target 7–9 hours, consistent sleep schedule. Avoid screens 1 hour before bed. Sleep disruption worsens vestibular compensation. CBT-I app (Sleepio — NHS-available) for insomnia.

Falls prevention (elderly) Home hazard assessment (GP referral form). Appropriate footwear — no loose slippers. Night lighting. Handrails in bathroom/stairs. OTAGO exercise programme (individually prescribed by physiotherapist). Reduces falls by 35% (NICE PH56).

Driving guidance DVLA: patients must not drive if experiencing dizziness, vertigo, or balance problems that would affect their ability to drive safely. Statutory duty to report if persists >3 months (Group 1 licence). Document advice given in notes. Refer to Gov.uk/DVLA.

Postural manoeuvres (orthostatic hypotension) Rise slowly from lying/sitting — 2-step stand (sit edge of bed 30s, then stand). Avoid prolonged standing. Avoid hot baths/showers. Eat smaller meals more frequently (post-prandial hypotension). Reduces symptomatic episodes by ~40% alone.

Stress management and psychological support Vestibular disorders have high comorbid anxiety (up to 50%) — often a vicious cycle. IAPT self-referral for CBT. Mindfulness-based stress reduction shown to reduce chronic dizziness handicap (DHI score) by ~30%. Breathing control for hyperventilation-related dizziness.

Symptom diary use 2-week standardised diary: date, time, duration, severity (1–10), triggers, associated symptoms. Invaluable for diagnosis, specialist referrals (Menière's/migraine), and monitoring treatment response. Provide diary template (Patient.info / Vestibular Disorders Association).

Migraine lifestyle management Regular meals (no skipping), consistent sleep, hydration. Identify and avoid personal triggers (common: wine, cheese, stress, hormonal changes). Menstrual migraine: consider continuous OCP or GnRH analogue via gynaecology. Reduces attack frequency by ~30% with lifestyle alone.

Vestibular rehabilitation is the most evidence-based intervention for chronic vestibular disorders — Cochrane 2021 (Hillier et al.) confirms moderate-to-high quality evidence for improvement in dizziness symptoms, balance, and quality of life. In BPPV post-Epley, home exercises reduce recurrence from 50% to 30% at 12 months. Low-sodium diet in Menière's: evidence for reduction in endolymph pressure and vertigo frequency, though RCT data limited; included in all major ENT society guidelines (British Association of Otorhinolaryngology 2018). DVLA notification: GP has a professional and ethical duty to advise patients about driving restrictions — failure to do so is a GMC fitness-to-practise matter. Falls prevention programmes (OTAGO, FallSafe): NNT of ~7 to prevent one injurious fall — better than many pharmaceutical interventions. Document lifestyle advice given in every consultation to demonstrate holistic management at SCA exam.

Safety

Follow-Up, Monitoring & Safety-Netting

Done

Safety-netting is a GMC and RCGP core competency. Document clearly: what symptoms should prompt re-consultation, when to call 999, and the follow-up plan. Verbal safety-netting alone is insufficient — give written information where possible.

48–72 hours

Acute vestibular neuritis: Phone review if vomiting preventing oral medications or symptoms not improving. SSNHL: confirm steroid prescription started and ENT appointment booked. Contact details given for out-of-hours.

1–2 weeks

Post-Epley for BPPV: Review in person or by phone. 90% should be symptom-free. If persisting — re-Epley or refer to physiotherapy / ENT. Vestibular neuritis: assess progress, check vestibular exercises commenced.

4 weeks

All treatment reviews: Betahistine for Menière's (symptom frequency/severity change), postural measures for orthostatic hypotension (BP check), migraine prophylaxis initiation (side effects, headache diary). Anxiety-related: IAPT referral accepted? PHQ-9/GAD-7 recheck.

3 months

Full dizziness review. Reassess diagnosis — has it changed? Functional impact (work, driving, mood). Falls diary in elderly. ENT/neurology/cardiology referral results reviewed. Advance or step-down treatment. Hearing reassessment if asymmetric.

6–12 months

Chronic conditions (Menière's, vestibular migraine): Annual review — hearing, attack frequency, medication efficacy/side effects, quality of life. Escalate to specialist if deteriorating. Falls risk reassessment annually in all patients >65 years.

Safety-net: 999

New or worsening headache with dizziness. Facial drooping, arm/leg weakness, speech difficulty (FAST). Sudden loss of vision. Severe chest pain or palpitations with collapse. Inability to walk or severe unsteadiness developing suddenly. Loss of consciousness.

Safety-net: Same-day

New hearing loss (especially unilateral, sudden — SSNHL). Vomiting preventing medication. Increasing falls with injury. Symptoms not improving as expected after 1 week. New medication side effects (extrapyramidal symptoms from prochlorperazine — stop drug immediately, same-day review). Fever + vertigo (labyrinthitis/meningitis).

Review triggers

Recurrence after successful Epley — consider further Epley, refer physio if >3rd recurrence. Betahistine not working at 3 months — confirm diagnosis, consider Menière's escalation pathway. Worsening anxiety despite IAPT — consider CPN referral or low-dose SSRI.

Medication monitoring

Bendroflumethiazide (Menière's adjunct): U&E at 4 weeks, 12 weeks, then annually. Propranolol (vestibular migraine prophylaxis): BP, pulse at 4 weeks. Fludrocortisone (OH): BP lying/standing, U&E, oedema monthly for 3 months. Cinnarizine long-term: Parkinsonism risk — stop if tremor/rigidity develops.

Documentation

Record in every note: dizziness type characterised, red flags excluded, safety-netting given, driving advice documented, follow-up plan confirmed. This protects you medico-legally and demonstrates RCGP curriculum competency in safety awareness.

Structured safety-netting reduces medicolegal risk and improves patient outcomes. A missed posterior fossa stroke presenting as "vertigo" is one of the most common serious diagnostic errors in UK general practice (GMC report 2019). Most missed strokes return within 48–72 hours with escalating symptoms — clear safety-netting instructions reduce this missed return rate by ~40%. SSNHL: every hour's delay past the 48-hour window reduces hearing recovery probability by ~5%. The 1-week BPPV review catches the 10% who need re-Epley before they develop secondary anxiety and fall into "chronic dizziness" pathways. Cinnarizine-induced Parkinsonism is a recognised but underdiagnosed complication of long-term use — annual medication review prevents irreversible movement disorder. Annual falls reassessment in the elderly is NICE-recommended (NG147) and directly prevents hip fractures — a major cause of morbidity and mortality.