Vertigo — new presentation
0Stop — call 999 now — immediate transfer via the local stroke pathway
- Acute continuous vertigo (with nausea or vomiting and unsteadiness) and HINTS indicating stroke (normal head impulse, direction-changing nystagmus, skew) — or no trained clinician and BPPV or postural hypotension do not explain it → 999
- Cannot stand or walk unsupported, limb dysmetria; facial numbness, diplopia, dysarthria, dysphagia, limb weakness, vertical or direction-changing nystagmus, new deafness with vertigo → 999
- Worst-ever headache (± neck stiffness); neck pain (young, or after neck trauma or manipulation: dissection); syncope, chest pain, sweating or palpitations with vertigo → 999
- While waiting: ABCDE, glucose, focal neurology. Ramsay Hunt with airway or swallow compromise → 999
1Triage — true vertigo? then episode duration
| Episodes | Pattern → think |
|---|---|
| <1 minute | Rolling over, looking up, no hearing change → BPPV |
| Minutes–hours | 20 min–12 h + hearing loss, tinnitus, fullness → Ménière's · 5 min–72 h + migraine history → vestibular migraine |
| Days, constant | Post-viral → vestibular neuritis (labyrinthitis if hearing loss) — stroke until block 0 is clear |
| Progressive | Constant + progressive → central cause · months of one-sided hearing loss + imbalance → vestibular schwannoma |
2Screen — one row is enough
- Sudden hearing loss over ≤3 days, in the last 30 days (not wax or middle ear) → ENT or ED ≤24 h (NG98); with acute continuous vertigo → block 0
- Sudden loss >30 days ago, or worsening over 4–90 days; unilateral pulsatile tinnitus → ENT ≤2 weeks
- Ear pain + vesicles ± facial weakness (Ramsay Hunt) → Same-day ENT; protect the eye if it will not close
- Head injury before the vertigo → Same-day assessment; CT only if NG232 criteria met. Known cancer or HIV → Same-day MRI brain
- Atypical features not explained by a peripheral diagnosis → Same-day
3Assess — once blocks 0–2 are answered
☐ HR, BP (both arms if central concern), glucose ☐ Lying/standing BP: drop ≥20 systolic or ≥10 diastolic → orthostatic, not vertigo ☐ Otoscopy, whisper, Rinne, Weber ☐ Cranial nerves, cerebellar, stands unsupported? ☐ Dix–Hallpike if positional (trained, safe neck) ☐ Drugs: ototoxic, sedating, antihypertensive
HINTS only in acute continuous vertigo, trained examiner. ECG if presyncope, palpitations, syncope, exertion, chest pain or cardiac history. No routine CT head or carotid Doppler; no imaging for classic BPPV.
4Classify — only if the screen is negative
- BPPV — positive Dix–Hallpike: rotatory upbeat nystagmus, latency 5–20 s, <1 min, fatigable. Horizontal nystagmus → horizontal canal (supine roll test).
- Vestibular neuritis — severe continuous vertigo for days, no hearing loss; labyrinthitis adds one-sided hearing loss.
- Ménière's → audiometry, ENT. Vestibular migraine — headache may be absent.
- Medication-induced — review and rationalise.
- Uncertain — central signs or HINTS positive: central until proven otherwise; otherwise say so, name who reviews when.
5Treat today — only these
- BPPV: Epley in clinic (trained; caution unstable cervical spine); no medicine, no post-manoeuvre restrictions; self-Epley once side confirmed.
- Neuritis: prochlorperazine 3–6 mg buccal BD or 5 mg oral TDS, short course, a few days; then vestibular rehab. No routine steroids. Caution older adults, Parkinson's. Check doses in the SPC and local formulary.
- Ménière's: suppressant for attacks only; betahistine — time-limited trial may be considered after ENT assessment.
- Vestibular migraine: migraine measures; prophylaxis per migraine guidance (topiramate: pregnancy prevention programme).
6Refer routinely
- Ménière's → ENT; progressive one-sided or asymmetric hearing loss → audiology/ENT, consider MRI internal auditory meati.
- BPPV: review within 1 month; persisting despite correct treatment, atypical nystagmus or horizontal canal → ENT.
- Neuritis not improving → vestibular physio; persistent significant symptoms or recurrent → ENT (local practice). Vestibular migraine not responding → neurology. Recurrent falls → falls clinic.
7Never reassure by
- A normal limb examination or a normal early CT.
- An abnormal head impulse alone — it does not exclude stroke.
- HINTS done untrained, or in episodic vertigo.
- Neck pain with vertigo labelled "cervicogenic".
- Unterberger/Fukuda — not reliable for central versus peripheral.
- Early improvement — a posterior stroke can still evolve.
8Safety-net — say it, then document it
999 “Call 999 for double vision, slurred speech, facial or limb weakness, a sudden severe headache or new neck pain, new deafness with sudden constant vertigo, being unable to walk, chest pain or fainting.” Same day: “Contact us today if the vertigo gets worse at any time, or is not improving after 3–4 days; new ear pain, blisters or facial weakness; a fall with injury; or sudden or worsening hearing loss.”
Driving — record every time: no driving while vertigo, imbalance or medicine effects could impair control; DVLA notification depends on diagnosis, severity and recurrence — direct to current DVLA guidance; the patient normally notifies. Follow-up: BPPV within 1 month; neuritis 4–6 weeks; prochlorperazine stopped.