Dizziness in adults
0Stop — call 999 now — before any history
- New vertigo with any central sign (diplopia, dysarthria, dysphagia, facial or limb weakness, limb ataxia, new deafness, Horner's); cannot sit or walk unaided; direction-changing or vertical nystagmus; sudden severe headache or neck pain; GCS <15 or seizure → 999
- Systolic BP <90, pulse >120 or <40, new irregular rhythm; syncope on exertion, lying down, or after chest pain or palpitations; bleeding with postural collapse; glucose <4 mmol/L uncorrected → 999
- While waiting: ABCDE, observations, ECG only if it does not delay transfer, exact onset time. No vestibular sedative with central signs — it masks the picture.
1Triage — which of the four, and its timing
| Complaint | Timing / trigger → think |
|---|---|
| Vertigo | Seconds, positional → BPPV · days, continuous → neuritis or stroke · 20 min–12 h + hearing change → Ménière's |
| Presyncope | Standing → orthostatic · exertion → aortic stenosis, arrhythmia · prodrome → vasovagal |
| Unsteady | Only upright; progressive over weeks → central lesion, drug |
| Vague | Drugs, anaemia; anxiety only once measurements are normal |
2Screen — one row is enough
- Vertigo + new one-sided deafness: central signs or neck pain after trauma or manipulation → 999; sudden loss ≤30 days → ENT or ED ≤24 h
- Cardiac marker (exertional or supine syncope, no prodrome, palpitations, murmur, abnormal ECG) → Cardiology ≤24 h; ongoing arrhythmia, chest pain or injury → 999
- Postural + bleeding, vomiting, fever, abdominal or back pain over 50 → Same-day; shocked → 999. Pregnancy test if of reproductive age.
- Progressive deficit over weeks → MRI brain ≤2 weeks (NG12); papilloedema, seizure, rapid progression, cancer, immunosuppression → Same-day admission
- New or increased drug → review Same-day; aminoglycoside → stop, ask specialist. Head injury on anticoagulant → Same-day (NG232).
3Assess — once blocks 0–2 are answered
☐ Pulse, SpO₂, temperature, glucose ☐ Lying/standing BP (1, 3 min) if presyncope, falls, older or drug cause: drop ≥20 systolic, ≥10 diastolic, or systolic <90 ☐ ECG if presyncope, syncope, palpitations, exertion ☐ Nystagmus, skew, ears, Weber, Rinne ☐ Cerebellar, walks unaided? ☐ Dix–Hallpike if positional
HINTS+ only for continuous vertigo with nystagmus, trained examiner, never remote; none → stroke pathway. No CT for acute vertigo.
4Classify — only if the screen is negative
- BPPV — under a minute, positional, no hearing loss; positive Dix–Hallpike is the diagnosis.
- Vestibular neuritis — continuous for days, post-viral; abnormal head impulse, walks. Hearing loss → exclude sudden hearing loss and stroke first.
- Ménière's — 20 min–12 h, fluctuating one-sided hearing loss, tinnitus, fullness → audiometry, ENT. Vestibular migraine — 5 min–72 h, migraine history; headache may be absent.
- Orthostatic / vasovagal — find the cause. Posture, provocation, prodrome and normal ECG → no cardiac referral.
- Uncertain — say so, use block 6, name who reviews when. PPPD (≥3 months) is a diagnosis, not "anxiety".
5Treat today — only these
- BPPV: Epley at the same visit (trained; not in unstable cervical spine); Brandt–Daroff; review at 4 weeks. No sedatives.
- Acute neuritis: prochlorperazine (buccal if vomiting), cinnarizine or cyclizine; stop within about 3 days; caution if older. Check doses in the SPC and local formulary.
- Orthostatic: reduce or stop the culprit drug, correct volume, rise slowly; extra salt or fluid only after considering heart failure, CKD.
- Ménière's: no long-term betahistine on an unconfirmed label. Serious cause: transfer is the treatment.
6Refer routinely
- Asymmetric hearing loss with imbalance → Urgent ENT/audiology for MRI (NG98); Ménière's → ENT.
- BPPV failing two Epleys → ENT or vestibular physio; persistent neuritis symptoms (local practice) or PPPD → vestibular rehab.
- Unexplained recurrent syncope, normal ECG → cardiology. Vestibular migraine uncontrolled → neurology. Recurrent falls → falls assessment (NG249).
7Never reassure by
- Normal neuro exam or CT, young age, previous episode, viral prodrome.
- A normal head impulse in continuous vertigo — it is the alarm.
- A "negative HINTS" done remotely or untrained.
- A normal ECG after syncope — the history decides.
- Stopping a BP drug when the drop follows bleeding.
- "Labyrinthitis" with deafness, "anxiety", "just her age".
8Safety-net — say it, then document it
999 “Call 999 for weakness, numbness, slurred speech, double vision, severe headache or neck pain, being unable to walk on your own, or fainting on exercise or lying down.” Same day: “New deafness or ringing in one ear, black stools, chest pain, palpitations, or dizziness getting worse rather than settling — contact us today.”
Remote or OOH: see face to face or escalate if BP, pulse, glucose, ECG, eyes, gait or hearing cannot be checked; vertigo ongoing on the call; any blackout; cannot walk unaided; new deafness, headache or neck pain; frail or anticoagulated. Driving — record every time: no driving if symptoms or sedating drugs could impair control; check DVLA guidance (notify if episodes are sudden, disabling and unprovoked). After one unexplained syncope, stop pending assessment.