Dizziness Algorithm

Safety

Red Flags — Exclude Life-Threatening Causes First

Done

Dizziness is a common presentation in general practice. 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 only if trained and experienced; if no competent examiner, refer immediately for stroke assessment

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) → Immediate referral NICE NG98: sudden loss (over 3 days or less) within the past 30 days, not explained by ear canal or middle ear causes → seen within 24 hours (ENT, audiovestibular medicine or emergency care); sudden loss more than 30 days ago, or rapidly worsening over 4–90 days → urgent referral within 2 weeks

New nystagmus + vertical/direction-changing Direction-changing nystagmus or pure vertical nystagmus → 999 Central cause — brain stem / cerebellum; immediate stroke/neuroimaging assessment, imaging modality per the hyperacute stroke pathway (MRI often required)

Unintentional weight loss + constitutional symptoms Night sweats, lymphadenopathy, anorexia → Suspected cancer 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 → assess using the current NICE head-injury pathway (NG232). Emergency imaging or assessment if head-injury CT criteria are met, especially with anticoagulation, age-related risk, worsening headache, vomiting, reduced consciousness or focal neurology. Not every post-traumatic dizziness needs same-day CT.

Neck pain + vertigo (esp. young / after neck trauma, manipulation) → 999 Vertebral artery dissection — a leading cause of posterior stroke in the under-50s; do not attribute to 'cervicogenic dizziness'

Posterior circulation stroke can mimic benign vertigo. In acute vestibular syndrome, the HINTS exam (Head Impulse, Nystagmus, Test of Skew) helps distinguish cerebellar stroke from vestibular neuritis only when performed by a clinician trained and experienced in its use (NICE NG127) — an abnormal head impulse test (HIT+) favours a peripheral cause; a normal head impulse test, direction-changing nystagmus or skew deviation should prompt immediate stroke/neuroimaging referral. Do not describe a "negative HINTS" as reassuring if the examination has not been performed correctly. SSNHL needs to be seen within 24 hours (NG98); steroid treatment for idiopathic SSNHL is decided with ENT — GPs should not start systemic steroids instead of referring (the Cochrane review, Wei et al., 2013, found the evidence of benefit uncertain). Missing a cardiac arrhythmia is dangerous, especially in older people 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)? If there was actual transient loss of consciousness, follow the TLoC pathway (CG109): 12-lead ECG and urgent cardiovascular referral for red flags (ECG abnormality, exertional TLoC, heart failure, murmur, family history of sudden cardiac death, unexplained breathlessness).

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: commonly BPPV, but brief arrhythmias and other causes occur | Minutes: migraine or arrhythmia | Hours: Menière's disease or vestibular migraine (5 minutes to 72 hours, NG127) | Days: vestibular neuritis, labyrinthitis or stroke. Duration guides but does not decide. Dizziness alone is not usually a TIA — sudden dizziness with new gait ataxia, dysarthria, diplopia, unilateral weakness, sensory deficit or new hearing loss is a possible posterior circulation stroke.

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.

Pathway at a glance — keep dizziness, syncope, acute vestibular syndrome, hearing loss and falls separate

1 · Define the symptom

Vertigo · presyncope · disequilibrium · non-specific dizziness.

2 · Screen for emergencies

Sudden focal neurological signs · new inability to walk · vertical or direction-changing nystagmus · sudden hearing loss · thunderclap headache · exertional syncope/presyncope · abnormal ECG · haemodynamic instability · recent head injury meeting NICE CT criteria.

3 · Identify the time pattern

Brief, triggered: BPPV · continuous hours–days: acute vestibular syndrome · recurrent spontaneous minutes–hours: vestibular migraine/Menière's/arrhythmia · postural near-faint: orthostatic/reflex/cardiac · persistent imbalance: multifactorial, vestibular, neurological or medication-related.

4 · Examine selectively

Postural BP when presyncope/falls suspected · ECG where a cardiovascular cause is plausible · gait, cerebellar signs, cranial nerves and nystagmus · Dix–Hallpike for suspected BPPV · otoscopy, hearing assessment and tuning fork tests where auditory symptoms are present.

5 · Treat the cause

Epley for confirmed BPPV · short-term antiemetic/vestibular suppressant only for severe acute symptoms · vestibular rehabilitation after the acute phase · medication review and orthostatic measures · ENT/audiological assessment for hearing loss or suspected Menière's · migraine-directed management for likely vestibular migraine · falls assessment and progressive strength/balance exercise for older adults.

Dizziness is a symptom, not a diagnosis. Failure to characterise type is the most common GP error in managing dizziness. Timing and triggers narrow a long differential to a short list. The TITRATE framework (Timing, Intensity, Triggers, Associated symptoms) gives structured enquiry, and is more useful than a "let's do some tests" approach. A symptom diary helps characterise 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. A common cause of vertigo in primary care. Do not use HINTS for BPPV.

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 (trained and experienced examiner only): ABNORMAL head impulse test (corrective saccade) is consistent with a peripheral cause — reassuring only as part of a correctly performed full HINTS; a NORMAL head impulse in constant vertigo is the central alarm.

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/audiology.

Vestibular migraine

Episodic vertigo (5 minutes to 72 hours, NG127) + 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 required when a cardiovascular cause is plausible.

Anxiety / hyperventilation

Persistent, non-episodic, worse in crowds/enclosed spaces, associated with breathlessness, tingling extremities, PHQ-9/GAD-7 elevated. Diagnose only after organic causes and abnormal measurements are addressed; consider PPPD.

Multifactorial (elderly)

Comprehensive falls assessment (NG249) — based on age, falls history, frailty, injury and gait/balance impairment; do not use falls-risk prediction tools. 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 the Epley manoeuvre, which is usually effective — no drugs needed. Vestibular neuritis may need a short course of vestibular suppressant for severe symptoms, then rehabilitation. Menière's needs audiological/ENT assessment; evidence for betahistine and dietary restriction is limited. Vestibular migraine follows migraine principles and is often specialist-led. Medication-related dizziness often improves with deprescribing. Getting this step wrong means patients receive the wrong treatment for months. 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

Highly appropriate in presyncope, falls, older adults and suspected autonomic/medication-related dizziness (not needed in every patient). Lying → standing, after 1 min and 3 min. Orthostatic hypotension: SBP drop ≥20 mmHg or DBP drop ≥10 mmHg within 3 minutes of standing. A heart-rate rise of ≥30 bpm alone does not diagnose POTS — POTS requires sustained orthostatic tachycardia (usually ≥30 bpm within 10 minutes of standing) without orthostatic hypotension, chronic orthostatic symptoms and exclusion of other causes; diagnosis is specialist-led. 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 warning sign → immediate stroke/neuroimaging assessment (not an automatic CT head). 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 a supine roll test when the history strongly suggests positional vertigo. Trained clinicians only; avoid in unstable cervical spine disease, and use caution with severe neck disease, vertebrobasilar insufficiency or inability to tolerate neck extension. Do not use HINTS for BPPV.

HINTS exam

Warning: HINTS is unsafe to interpret without specific training. For acute vestibular syndrome (sudden persistent vertigo, nausea/vomiting, gait unsteadiness, usually spontaneous nystagmus, lasting hours to days), use HINTS only if trained and experienced. If no competent HINTS examiner is available, refer immediately for stroke assessment. HINTS is not appropriate for brief, triggered positional vertigo, presyncope, chronic imbalance or isolated dizziness. H=Head Impulse Test (abnormal=peripheral), I=nystagmus (unidirectional=peripheral), TS=Test of Skew (vertical skew=central). A normal head impulse test, direction-changing nystagmus or skew deviation → immediate stroke/neuroimaging referral (999).

Cerebellar signs

Finger–nose test, heel–shin test, rapid alternating movements, gait assessment. Ataxia + nystagmus = cerebellar lesion until proven otherwise → immediate stroke/neuroimaging assessment per the hyperacute stroke pathway. Use Romberg as part of a broader neurological and gait assessment. It does not reliably distinguish vestibular from proprioceptive disease, and marked gait/truncal ataxia with eyes open is a central red flag.

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) can support gait/balance assessment, but no single TUG time is a universal threshold for significant fall risk. Observe: antalgic, broad-based (cerebellar), steppage (peripheral neuropathy), slow shuffling (Parkinsonism). In older adults, offer comprehensive falls assessment based on age, falls history, frailty, injury and gait/balance impairment (NG249).

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.

A positive Dix-Hallpike test supports BPPV — it removes the need for imaging and justifies an Epley manoeuvre. The HINTS exam performs well for central cause only in trained and experienced hands (Kattah et al., NEJM 2009; NICE NG127) — it is unsafe to interpret without specific training. Postural BP is often the treatable cause in older patients with presyncope or falls. Omitting neurological and gait examination in new dizziness risks missing posterior circulation stroke.

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.

Classic BPPV

Dix–Hallpike; no routine bloods or imaging.

Presyncope/syncope

Lying/standing BP, ECG, cardiovascular assessment.

Acute vestibular syndrome

Full neurological/gait examination; trained HINTS or immediate stroke referral.

Hearing loss/tinnitus

Otoscopy, tuning fork/audiological assessment; urgent pathway if sudden.

Falls/disequilibrium in older adult

Falls assessment, medication review, gait/balance, vision, hearing and cardiovascular assessment.

Suspected systemic cause

Targeted FBC, U&E, glucose, TFTs, LFTs, etc.

ECG Targeted

Perform ECG for presyncope, syncope, palpitations, exertional symptoms, unexplained collapse, relevant cardiac history or abnormal cardiovascular examination. It is not required routinely for classic BPPV or uncomplicated peripheral vestibular disease. 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 — targeted

Not required for all dizziness; a patient with typical BPPV does not need routine bloods. FBC: suspected anaemia or bleeding. U&E: suspected dehydration, renal disease, electrolyte disturbance or medication toxicity. Glucose: diabetes (check for and treat hypoglycaemia, NG127), compatible symptoms or acute illness. TFTs: symptoms/signs of thyroid disease or relevant medication. LFTs: suspected liver disease or alcohol-related illness. Pregnancy test where clinically relevant. Troponin/D-dimer only when clinically indicated.

Postural BP monitoring

Do not arrange routine 24-hour ABPM for every person with confirmed orthostatic hypotension. First address medication, volume depletion, anaemia, autonomic disease, cardiac causes, and postprandial and environmental triggers. ABPM may help in selected cases (e.g. 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. Routine audiology referral unless sudden or rapidly worsening hearing loss (NG98 urgent pathways).

MRI brain + IAMs

MRI of the internal auditory meati, directed by: asymmetric or unilateral sensorineural hearing loss, unilateral persistent tinnitus, neurological signs, atypical features, or concern about vestibular schwannoma. Suspected central cause → stroke/neuroimaging pathway. NOT: routine for typical Menière's disease solely because symptoms persist, or first-line for classic BPPV or clear vasovagal. CT head after trauma only if NICE head-injury CT criteria (NG232) are met.

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 a substantial amount each year. ECG is essential when the history suggests a cardiovascular cause (presyncope, syncope, palpitations, exertional symptoms), and QTc prolongation from commonly prescribed drugs (macrolides, antidepressants, antihistamines) is an underrecognised cause. Bloods are targeted to the suspected cause rather than used as a screen. 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, haemodynamic collapse, new AF with rapid ventricular response, complete heart block.

Same-day

Acute SSNHL (sudden loss over 3 days or less, within the past 30 days, not explained by ear canal or middle ear causes) — refer immediately to ENT or ED, to be seen within 24 hours (NG98); not a 999 call unless stroke is suspected. Severe postural hypotension with falls and injury risk. Dizziness after head trauma meeting NICE head-injury CT criteria (NG232), including anticoagulated patients. Arrhythmia on ECG requiring cardiology input. Syncope with CG109 red flags (ECG abnormality, heart failure, exertional syncope, family history of sudden death under 40, new breathlessness or murmur) → specialist cardiovascular assessment within 24 hours. Severe Menière's attack with vomiting — may need IV prochlorperazine in acute trust setting.

2 weeks

Sudden hearing loss more than 30 days ago, or hearing loss worsening rapidly over 4–90 days → urgent referral within 2 weeks (NG98). Asymmetric SNHL + tinnitus ± dizziness (vestibular schwannoma) → urgent ENT/audiology for MRI of the internal auditory meati (NG98; not a suspected-cancer pathway). Atypical nystagmus not fitting peripheral pattern — urgent MRI referral via neurology.

Routine ENT

Suspected Menière's disease — audiological/ENT assessment; thiazides, intratympanic treatment and surgery are specialist-led decisions. Chronic otitis media with hearing loss. Cholesteatoma (urgent routine if suspected).

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 (chronic orthostatic symptoms with sustained orthostatic tachycardia, usually ≥30 bpm within 10 minutes of standing, without orthostatic hypotension — specialist-led diagnosis). 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 — refer early in the pathway.

Falls service / Physio

Older patient with disequilibrium, gait/balance impairment, frailty, injury or previous falls — comprehensive falls assessment and progressive, individually tailored strength and balance exercise (NG249). 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, NHS Talking Therapies). Medication side effect (deprescribe or substitute). Vestibular neuritis in recovery phase (VR exercises).

Much dizziness is safely managed in primary care when correctly assessed. However, vestibular schwannoma (acoustic neuroma) presents with unilateral SNHL + tinnitus; early MRI detection (via urgent ENT/audiology referral) improves outcomes and preserves facial nerve function. Vestibular rehabilitation improves chronic unilateral vestibular dysfunction symptoms (McDonnell and Hillier, Cochrane 2015). Falls assessment and strength and balance programmes are recommended by NICE NG249. Timely Menière's ENT/audiology referral allows specialist treatment options to be considered.

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 (trained clinician; avoid in unstable cervical spine disease). Epley is usually effective and may provide rapid relief; symptoms may recur and repeat treatment may be required. 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)

If required for severe acute vertigo or vomiting, use a vestibular suppressant/antiemetic for the shortest possible duration, usually no more than 2–3 days. Avoid prolonged use, particularly in older adults because of sedation, falls, anticholinergic effects and extrapyramidal reactions. Check specific doses against the current SPC/local formulary.

Acute phase (<72h, severe)

Prochlorperazine Short course

Buccal (dose per current SPC/BNF/local formulary) for max 2–3 days; IM (dose per NICE/SPC) if vomiting prevents buccal use. DO NOT continue beyond 3 days — delays vestibular compensation. Caution in older people — extrapyramidal risk.

Alternative

Cinnarizine OTC available

Dose per current SPC/BNF/local formulary — shortest possible duration, usually no more than 2–3 days (like all vestibular sedatives it delays central compensation if continued). H1 antihistamine. Not safer than prochlorperazine in older people: can cause sedation and extrapyramidal/parkinsonian adverse effects — warn patient. Cyclizine (dose per NICE/SPC) is an 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 — Specialist-Led Management (no NICE treatment ladder)

Step 1Refer suspected Menière's disease for audiological/ENT assessment. Discuss lifestyle measures and local specialist treatment options. Evidence for betahistine and dietary restriction is limited; betahistine is used in practice but is not a proven disease-modifying therapy. Review treatment according to attack frequency, hearing status and patient preference. Avoid a fixed sodium target unless the local ENT service recommends one.

Step 2Thiazide diuretic — specialist-led decision only; electrolyte monitoring per the specialist plan.

Step 3Intratympanic therapy (specialist only): methylprednisolone (hearing preservation) or gentamicin (vestibulotoxic — for intractable vertigo, hearing already poor). Meniett devices are not a routine evidence-based treatment.

Step 4Surgical options (ENT only): vestibular neurectomy, endolymphatic sac decompression, labyrinthectomy (for non-hearing ear) — specialist decision.

Vestibular Migraine

Treatment follows migraine principles and is often specialist-led. Use local migraine guidance and document off-label use where applicable. There is no universally accepted primary-care vestibular migraine regimen. Choose drugs considering migraine phenotype, comorbidity, pregnancy potential, contraception, mood, blood pressure and cognitive adverse effects.

Acute attack

Triptans Migraine Rx

May be appropriate for migraine headache, but evidence for vertigo alone is limited. Doses per BNF/local migraine guidance. Aspirin 900 mg + antiemetic (metoclopramide 10 mg) as alternative first-line.

Prophylaxis (frequent or disabling attacks)

Migraine prophylaxis Off-label · specialist-guided

Propranolol, amitriptyline and topiramate are off-label for vestibular migraine — document off-label use; doses per BNF/local guidance. Topiramate is teratogenic: follow current MHRA pregnancy-prevention advice where relevant.

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.

Orthostatic Hypotension / Vasovagal — staged approach

Step 1Medication review: deprescribe/reduce antihypertensives, alpha-blockers, diuretics, tricyclics. Correct dehydration and anaemia; address heat exposure.

Step 2Slow position changes and physical counterpressure manoeuvres: leg crossing, muscle tensing before standing. Consider compression garments. Raised head of bed. Any increase in salt or fluid only after considering heart failure, CKD, hypertension, electrolyte disturbance, urinary retention and supine hypertension.

Step 3Refer for specialist treatment if persistent or neurogenic. Drug treatment (e.g. fludrocortisone, midodrine) is a specialist decision, with monitoring for supine hypertension, electrolytes, oedema and heart failure.

Anxiety-related
dizziness

Do not prescribe vestibular sedatives — they reinforce somatic focus. NHS Talking Therapies referral for CBT (specifically vestibular-oriented CBT or dizziness-specific CBT). Breathing retraining for hyperventilation. Consider an SSRI (dose per NICE/SPC) if anxiety persists after psychological 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.

Next steps: see BPPV · Vestibular neuronitis · Ménière's disease · Migraine · Vasovagal syncope · Stroke and TIA

The Epley manoeuvre is usually effective for BPPV yet is underused in primary care. Prolonged vestibular suppressant prescription is a common treatment error — it inhibits vestibular compensation and prolongs recovery from vestibular neuritis. Betahistine for Menière's: evidence of benefit is limited and it is not a proven disease-modifying therapy. Vestibular rehabilitation post-neuritis improves recovery (McDonnell and Hillier, Cochrane 2015). Drug treatment for orthostatic hypotension is specialist-led; most patients start with medication review and non-drug measures.

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. Improves chronic vestibular symptoms after the acute phase. Prescribe as specifically as a drug — Physio referral or NHS resources (NHS website or local physiotherapy leaflets).

Hydration and sodium balance For Menière's: avoid a fixed sodium target unless the local ENT service recommends one — excessive salt restriction can be inappropriate. For orthostatic hypotension: correct dehydration; any extra fluid or salt only after considering heart failure, CKD, hypertension, electrolyte disturbance and supine hypertension.

Caffeine and alcohol reduction Both worsen Menière's (endolymph pressure) and vestibular migraine. Alcohol: national guidelines <14 units/week. Caffeine: reduce if it is a personal trigger. 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. Progressive, individually tailored strength and balance exercise, supervised where appropriate (e.g. OTAGO, prescribed by physiotherapist). Do not use falls-risk prediction tools to predict risk; offer comprehensive falls assessment based on age, falls history, frailty, injury and gait/balance impairment. Reduced falls by about 35% in the Otago programme trials (Robertson et al., meta-analysis 2002); NICE NG249 recommends strength and balance programmes for people at risk of falls.

Driving guidance Do not drive if dizziness, vertigo, imbalance, sedating medication or an unpredictable episode could impair safe control of the vehicle. Advise the patient to check the current DVLA guidance. Notification is required where episodes are sudden, disabling and unprovoked/unprecipitated, or where another relevant diagnosis applies (DVLA Assessing fitness to drive). 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).

Stress management and psychological support Vestibular disorders commonly coexist with anxiety — often a vicious cycle. NHS Talking Therapies self-referral for CBT. Mindfulness-based approaches may help some people with chronic dizziness. 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 (practice template or 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: continuous combined hormonal contraception only if migraine without aura (check UKMEC; aura is UKMEC 4); GnRH analogues are specialist-only via gynaecology.

Vestibular rehabilitation is the most evidence-based intervention for chronic vestibular disorders — the Cochrane review (McDonnell and Hillier, 2015) found moderate-to-strong evidence for improvement in dizziness symptoms, balance, and quality of life. BPPV can recur after Epley, and repeat treatment may be needed. Low-sodium diet in Menière's: evidence is limited; follow local ENT advice rather than a fixed target. 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: NICE NG249 recommends progressive, individually tailored strength and balance programmes for people at risk of falls. 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 seen within 24 hours by ENT/audiovestibular service; steroids only per local ENT protocol. Contact details given for out-of-hours.

1–2 weeks

Vestibular neuritis: assess progress, check vestibular exercises commenced.

4 weeks

Post-Epley for BPPV: Review in person or by phone. Most improve; symptoms may recur. If persisting — re-Epley or refer to physiotherapy / ENT. All treatment reviews: Menière's treatment per ENT plan (attack frequency, hearing status, patient preference), postural measures for orthostatic hypotension (BP check), migraine prophylaxis initiation (side effects, headache diary). Anxiety-related: NHS Talking Therapies 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. Ask about falls annually in people aged 65 and over and offer comprehensive falls assessment where indicated (NG249).

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. Menière's symptoms not controlled — confirm diagnosis and discuss specialist options with ENT. Worsening anxiety despite NHS Talking Therapies — consider CPN referral or low-dose SSRI.

Medication monitoring

Thiazide (if started by ENT for Menière's): U&E per specialist plan. Propranolol (off-label vestibular migraine prophylaxis): BP, pulse at 4 weeks. Fludrocortisone/midodrine (if started by a specialist): lying/standing BP including supine hypertension, U&E, oedema per specialist plan. Cinnarizine: not for long-term use — sedation and 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. Missed strokes may return with escalating symptoms — clear safety-netting instructions help patients return promptly. SSNHL: NG98 asks for sudden hearing loss to be seen within 24 hours, so the safety-net must say same day. The BPPV review catches those who need repeat Epley before they develop secondary anxiety and fall into "chronic dizziness" pathways. Cinnarizine-induced parkinsonism is a recognised complication — vestibular suppressants should not be continued long-term. Asking older people about falls and offering assessment to those who have fallen is recommended in NICE NG249 (2025) and directly prevents hip fractures — a major cause of morbidity and mortality.