Vertigo Algorithm

Safety

Exclude Central & Life-Threatening Causes First

Done

Assess ABCDE, glucose (in diabetes, check for and treat hypoglycaemia — NG127), gait and focal neurology. Screen for central, vascular and dangerous causes before assuming peripheral pathology. The majority of vertigo is benign — but missing a posterior fossa stroke or cerebellar bleed is catastrophic.

Acute vestibular syndrome + HINTS indicating stroke Sudden-onset continuous vertigo/dizziness with nausea or vomiting and gait unsteadiness. HINTS only by a clinician trained and experienced in it: normal head impulse, direction-changing nystagmus or skew deviation → Immediate stroke/neuroimaging pathway (call 999 — immediate transfer via the local stroke pathway). An abnormal head impulse alone does not exclude stroke. If no trained clinician is available, refer immediately via the local stroke pathway when BPPV/postural hypotension do not explain symptoms.

Severe gait/truncal ataxia New inability to stand or walk unsupported, or new limb dysmetria → Immediate stroke/neuroimaging pathway (call 999 — immediate transfer via the local stroke pathway) — cerebellar stroke / haemorrhage

New focal neurological deficit Facial numbness, diplopia, dysarthria, dysphagia, limb weakness, vertical or direction-changing nystagmus, or new deafness alongside vertigo → Immediate stroke/neuroimaging pathway (call 999 — immediate transfer via the local stroke pathway) — brainstem / cerebellar CVA

Thunderclap or severe headache Worst-ever headache with vertigo / neck stiffness → 999 subarachnoid haemorrhage or posterior fossa bleed

Cardiovascular compromise Syncope, chest pain, significant diaphoresis, or palpitations with vertigo → 999 arrhythmia, MI, aortic dissection

Sudden hearing loss With acute continuous vertigo → treat as central: immediate stroke pathway (above). Exclude wax and acute external/middle-ear disease. Onset over ≤3 days within the past 30 days, not explained by ear canal or middle ear causes → ENT/ED within 24 h (NICE NG98). Causes include idiopathic SSNHL, labyrinthitis and vascular disease; steroid decisions per urgent ENT pathway

Ear pain + vesicles + facial weakness Otalgia, rash around pinna or canal, ± VII nerve palsy → Same-day ENT/acute Ramsay Hunt syndrome — early antiviral and corticosteroid may be considered per ENT/local facial-palsy protocol. Assess eye closure; urgent eye protection if facial weakness. Urgent review if unable to close the eye, corneal symptoms, dysphagia/airway compromise or multiple cranial-nerve involvement

Head trauma preceding vertigo Recent head injury → Same-day assess against NICE NG232 (temporal bone fracture, haemolabyrinth); CT head only if the NG232 criteria are met

Neck pain + vertigo (young / after neck trauma or manipulation) → 999 Vertebral artery dissection — a leading cause of posterior stroke under 50; never dismiss as "cervicogenic"

Immunocompromised / malignancy history Vertigo + known cancer or HIV → Same-day MRI brain — exclude CNS metastasis or CNS opportunistic infection

Gradual progressive unilateral loss + vertigo Months of unilateral hearing loss with imbalance → Audiology / ENT consider MRI internal auditory meati to exclude vestibular schwannoma; urgency depends on onset, progression and focal signs

Why this order matters: Posterior circulation strokes are the most dangerous missed diagnosis in vertigo and are often initially misdiagnosed. The HINTS exam (Head Impulse, Nystagmus, Test of Skew) can identify a central cause in acute continuous vertigo, but NICE NG127 limits it to appropriately trained clinicians and recommends immediate referral for neuroimaging when HINTS indicates stroke. Early imaging, including CT, can be falsely negative. Use HINTS only in acute sustained vertigo (not episodic). Sudden hearing loss follows NICE NG98 referral timelines, with steroid decisions made through the urgent ENT pathway. Ramsay Hunt needs same-day assessment and eye protection if eye closure is impaired.

Diagnose

Characterise the Vertigo — History is the Diagnosis

Done

Vertigo is almost always diagnosed on history. Ask these five key questions systematically.

True vertigo?

Distinguish vertigo (false sense of rotation — "room spinning") from pre-syncope ("going to faint"), disequilibrium (balance problem walking), or non-specific dizziness. Only true vertigo fits this pathway.

Onset & duration of episodes

Seconds–minutes → BPPV most likely (position-triggered)
Minutes–hours → Ménière's disease or vestibular migraine
Days (constant) → Vestibular neuritis / labyrinthitis
Constant + progressive → Central cause; urgent imaging

Triggers

Rolling over in bed, looking up (Dix-Hallpike positive) → BPPV. No positional trigger, spontaneous → neuritis/Ménière's. Stress, period, sleep deprivation → vestibular migraine

Associated symptoms

Unilateral tinnitus + hearing loss + ear fullness → Ménière's (triad). Headache + photophobia + aura → vestibular migraine. Preceding URTI → vestibular neuritis

Medication review

Aminoglycosides, loop diuretics, cisplatin, quinine → ototoxicity. Antihypertensives, opioids, benzodiazepines, antiepileptics → central dizziness. Review all medications.

Vascular risk factors

HTN, AF, diabetes, smoking, hyperlipidaemia — context only; do not use a vascular risk score for triage. The clinical syndrome and examination matter more.

The duration of individual episodes is the single most diagnostically powerful piece of history in vertigo. BPPV episodes last <1 minute; Ménière's lasts 20 minutes–12 hours; vestibular neuritis produces continuous vertigo for days. Medication-induced dizziness is common in older adults — always review the drug chart before labelling a diagnosis.

Diagnose

Classify the Cause — Peripheral vs Central

Done

Categorise into the most likely diagnosis to guide examination and treatment:

BPPV Most common

Brief (<1 min) positional vertigo triggered by head movement (rolling in bed, looking up). No hearing change. Resolves with Epley.

Vestibular Neuritis

Sudden-onset severe continuous vertigo lasting days, subsiding over weeks. No hearing loss. Often post-viral. Nausea and vomiting prominent. Spontaneous horizontal nystagmus typical, but direction alone is not reliable. Clinical diagnosis — exclude central causes where appropriate.

Labyrinthitis

As vestibular neuritis plus unilateral hearing loss. Cochlear involvement distinguishes from pure neuritis.

Ménière's Disease

Episodic attacks lasting 20 min–12 hours. Triad: vertigo + unilateral fluctuating low-frequency SNHL + tinnitus + aural fullness. Arrange audiometry; specialist diagnosis if recurrent, atypical or associated with significant hearing loss.

Vestibular Migraine

Recurrent vestibular episodes generally lasting 5 minutes to 72 hours, with a history of recurrent migrainous headache (NICE NG127). May occur without headache. Phono/photophobia common. Managed along migraine lines.

Central (posterior fossa)

Direction-changing nystagmus, vertical nystagmus, diplopia, dysarthria, dysphagia, ataxia, or HINTS positive → central until proven otherwise. Do not manage in primary care.

Medication-induced

Bilateral vestibular toxicity (aminoglycosides), or generalised dizziness (antihypertensives, antiepileptics). Review and rationalise medications.

BPPV is the commonest cause of peripheral vertigo. Vestibular migraine is significantly under-diagnosed — it is the second most common cause of recurrent vertigo after BPPV. Correct classification prevents both under-treatment (missing Ménière's requiring audiometry and ENT follow-up) and over-investigation (ordering unnecessary MRI for classic BPPV). The peripheral vs central distinction is the most safety-critical decision in this pathway.

Diagnose

Targeted Examination — Dix-Hallpike & HINTS

Done

Perform a focused neurotological examination — these findings change management:

Vital signs & lying/standing BP

HR and BP (both arms if central cause suspected). Postural drop (≥20 mmHg systolic or ≥10 mmHg diastolic, NICE NG136) → orthostatic dizziness, not true vertigo. AF → consider cardioembolic event.

Dix-Hallpike test BPPV

Only if trained and the cervical spine is safe. Lay patient from sitting to supine with head turned 45° to affected side, neck extended 20°. Positive: rotatory upbeat nystagmus with latency 5–20s, duration <1 min, fatigable on repeat. → Posterior canal BPPV confirmed. If horizontal nystagmus → horizontal canal BPPV (supine roll test instead).

HINTS exam Acute sustained

Only in acute continuous vertigo, and only if trained and experienced in HINTS. Head Impulse Test (normal head impulse = central concern; an abnormal head impulse alone does not exclude stroke), Nystagmus (direction-changing = central), Test of Skew (vertical ocular misalignment = central). HINTS indicating stroke → immediate stroke/neuroimaging pathway. If not trained, do not attempt — refer via the local stroke pathway.

Otoscopy

Inspect external canal and tympanic membrane. Vesicles → Ramsay Hunt. Cholesteatoma / perforation → ENT referral. Acute otitis media → antibiotics are not routinely needed (CKS, NICE NG91); see the hearing-loss pathway.

Hearing test (whisper / Rinne / Weber)

Unilateral sensorineural loss (Rinne positive bilaterally but Weber lateralises to good ear) → labyrinthitis, Ménière's, acoustic neuroma. Refer audiometry.

Cerebellar exam

Finger-nose, heel-shin, dysdiadochokinesia, gait. Ipsilateral limb ataxia + vertigo → cerebellar lesion → 999.

Romberg / Unterberger

Unterberger/Fukuda is not reliable for central vs peripheral — non-diagnostic, do not rely on it. Severe truncal instability or inability to stand unsupported = central concern.

Cranial nerve exam

V (facial sensation), VI (lateral gaze), VII (facial weakness), VIII (hearing). Multiple CN deficits → brainstem pathology → 999.

The Dix-Hallpike test has a reported 82% sensitivity and 71% specificity for posterior canal BPPV (AAO-HNS, international — Bhattacharyya et al. 2017; not a NICE figure). A positive Dix-Hallpike immediately directs to Epley — no further investigation needed. In research by expert examiners, the HINTS battery outperformed early MRI in the first 48 hours (reported sensitivity 100% vs 72%; Kattah et al., Stroke 2009 — a single-centre study, not a NICE figure). These figures come from trained examiners; NICE NG127 limits HINTS to appropriately trained clinicians. An untrained HINTS that falsely reassures is a serious, avoidable diagnostic error. Do not perform HINTS in episodic vertigo — it is only validated in acute sustained vertigo where a central stroke is the primary concern.

Diagnose

Investigations — Targeted, Not Blanket

Done

Most peripheral vertigo needs no investigations — diagnose clinically. Investigate when diagnosis is uncertain or red flags are present.

Classic BPPV No tests

Positive Dix-Hallpike with classic features → no investigations required. Proceed directly to Epley manoeuvre. Avoid unnecessary bloods or imaging.

ECG If indicated

When symptoms could be presyncope or arrhythmia — palpitations, syncope, exertional symptoms, chest pain or relevant cardiac history. Not routinely required for classic isolated BPPV or vestibular neuritis.

Audiometry

Refer if: unilateral hearing loss, suspected Ménière's (low-frequency SNHL characteristic), follow-up labyrinthitis, or acoustic neuroma suspected. Formal pure-tone audiogram via audiology.

Bloods

FBC (anaemia → pre-syncope), U&Es (hyponatraemia → dizziness), glucose (hypo/hyperglycaemia), TFTs (hypothyroidism → dizziness). Guided by history and examination; not required in classic BPPV.

Imaging Specialist

HINTS indicating stroke or central features → immediate stroke pathway imaging per local protocol (CT/CTA, MRI/MRA) — not outpatient gadolinium MRI. MRI internal auditory meati for unilateral/asymmetric SNHL or suspected vestibular schwannoma. Consider if BPPV is atypical or not responding, or MS suspected. Do NOT image classic BPPV or uncomplicated vestibular neuritis unless diagnosis uncertain, atypical or red flags emerge.

Caloric testing / VNG ENT/Audiology

Formal vestibular function testing — ordered by ENT or audiovestibular physician. Not a primary care investigation.

NOT routinely needed

CT head (low sensitivity for posterior fossa), carotid Doppler (unhelpful in vertigo), echocardiogram (only if cardiac source needed), MRA (specialist-initiated only).

Routine CT brain is inappropriate for BPPV and vestibular neuritis — the posterior fossa is poorly imaged by CT, giving false reassurance. If a central cause is suspected, imaging is arranged through the immediate stroke pathway (CT/CTA or MRI/MRA per local protocol), not from primary care. Over-investigation of BPPV contributes to NHS diagnostic inefficiency and patient anxiety. The AAO-HNS BPPV guideline (2017, international) advises against routine neuroimaging in classic BPPV. Audiometry is the key investigation to arrange in primary care when Ménière's or acoustic neuroma is suspected — it changes management and specialist referral pathway.

Refer

Referral Criteria — Know When to Escalate

Done

Immediate / 999

HINTS indicating stroke (trained clinician), or acute vestibular syndrome not explained by BPPV/postural hypotension where HINTS unavailable — immediate stroke/neuroimaging pathway (call 999 — immediate transfer via the local stroke pathway) · Acute cerebellar or brainstem signs · Thunderclap headache · Acute focal neurology · Ramsay Hunt with airway / swallow compromise

Same-day ED/Urgent

Sudden hearing loss over ≤3 days within the past 30 days (with acute continuous vertigo → stroke pathway above) — refer immediately to be seen by ENT or ED within 24 h (NICE NG98); steroid decisions per ENT pathway · Ramsay Hunt syndrome — same-day ENT/acute assessment per local facial-palsy protocol · Head trauma preceding vertigo · Atypical features not explained by a peripheral diagnosis

Urgent ENT (within 2 weeks)

Sudden hearing loss >30 days ago, or hearing loss worsening rapidly over 4–90 days (ENT or audiovestibular medicine, NICE NG98) · Unilateral pulsatile tinnitus

Routine ENT

Confirmed or suspected Ménière's disease (diagnosis, dietary advice, intratympanic steroids consideration) · Progressive unilateral/asymmetric hearing loss (audiology/ENT; consider MRI internal auditory meati) · BPPV with uncertain diagnosis, atypical nystagmus or persisting despite correctly performed treatment · Horizontal canal BPPV (log-roll technique) · Recurrent vestibular neuritis

Neurology

Suspected vestibular migraine not responding to primary care management · Suspected central cause once emergency excluded · MS workup

Audiovestibular Medicine

Complex vestibular disorders requiring caloric testing, posturography, VNG — referral via ENT or direct if available locally.

Primary Care Manage

Classic BPPV (Epley) · Uncomplicated vestibular neuritis (symptomatic, vestibular rehab) · Medication-induced dizziness (rationalise meds) · Orthostatic dizziness (lifestyle, review antihypertensives)

NICE NG98 (2018): hearing loss developing suddenly over 3 days or less within the past 30 days → refer immediately to be seen within 24 hours by ENT or the emergency department; sudden loss more than 30 days ago, or rapid worsening over 4–90 days → urgent referral within 2 weeks. Steroid treatment for idiopathic SSNHL (dose, timing, contraindications, intratympanic treatment) is decided through the urgent ENT pathway, never instead of referral; systematic reviews (Cochrane, Plontke 2022) show the size of benefit remains uncertain. Acoustic neuroma (vestibular schwannoma) presents insidiously and diagnosis is often delayed — unilateral/asymmetric SNHL should be assessed by audiology/ENT, with MRI of the internal auditory meati where indicated. Ménière's requires ENT for diagnosis confirmation (AAO-HNS criteria) and access to intratympanic therapy if dietary/medical measures fail.

Treat

Treatment by Diagnosis — Specific Pathways

Done

BPPV — First-line: Epley Manoeuvre (perform in-clinic)

Epley Manoeuvre

Posterior canal BPPV, first line, performed by a trained clinician. 4-position sequence. No medications needed. Caution in unstable cervical spine disease. Self-Epley at home only once the affected canal/side is confirmed and the patient can perform it safely. Routine post-manoeuvre restrictions are not needed.

Horizontal canal BPPV

Log-roll (Barbecue roll) or Gufoni manoeuvre — consider ENT referral if not trained. Direction of nystagmus on supine roll test determines affected ear.

Prochlorperazine Short-term only

3–6 mg buccal BD or 5 mg oral TDS (BNF). Check current BNF/SPC. Maximum 2–3 days, for severe nausea/vertigo only. Vestibular suppressants inhibit compensation — do NOT prescribe long-term in BPPV or persistent vestibular neuritis. Sedation, postural hypotension, extrapyramidal and anticholinergic effects — extra caution in older adults, Parkinson's disease, Lewy body dementia and QT risk. Review other sedating medicines and driving.

Vestibular Neuritis — Acute Phase Management

Acute nausea / vomiting (first 48–72h)

Prochlorperazine Short-term

3–6 mg buccal BD or 5 mg oral TDS (SPC). Short course of a few days only (often about 3 days in practice). Suppresses vomiting while central compensation begins; do not continue long term.

Residual imbalance (weeks 1–6)

Vestibular Rehabilitation First-line

Cawthorne-Cooksey or Brandt-Daroff exercises. Refer to vestibular physiotherapy. Useful for persistent imbalance. Reduce all vestibular suppressants.

Viral labyrinthitis (hearing loss)

No routine GP steroids

Steroid evidence in vestibular neuritis/labyrinthitis is mixed — do not start routinely for presumed viral labyrinthitis. If sudden hearing loss is present, follow the NICE NG98 urgent ENT pathway (steroid decisions by ENT).

Ménière's Disease — Stepwise Management

Step 1Audiometry + dietary trial — balanced diet without excessive salt restriction; caffeine/alcohol reduction and avoidance of individual triggers may be trialled. Evidence for specific salt, caffeine or alcohol thresholds is limited. Smoking cessation.

Step 2Betahistine — a time-limited trial may be considered after ENT or audiovestibular assessment; effectiveness uncertain. Dose and contraindications per current BNF/SPC (maintenance 24–48 mg daily in divided doses). Review at the agreed review point and stop if ineffective. Caution: asthma, peptic ulcer.

Step 3Vestibular suppressant (e.g. prochlorperazine, dose per current BNF/SPC) for acute attacks only, short term. Add vestibular rehab between attacks.

Step 4ENT referral — intratympanic gentamicin or steroid injections. Endolymphatic sac decompression. Vestibular nerve section for severe refractory cases.

Vestibular Migraine — Migraine Prophylaxis

Acute attack

Conventional migraine management Individualise

No single established acute treatment for vestibular migraine. A triptan may be tried for headache, but evidence for the vertigo component is limited; avoid triptans in cardiovascular disease. Short-term antiemetic for nausea. Migraine lifestyle measures.

Frequent or disabling attacks

Prophylaxis per migraine guidance Individualised

Choice depends on migraine phenotype, comorbidities and patient preference. Options include propranolol (unsuitable in asthma, bradycardia and some people with diabetes), amitriptyline or topiramate (MHRA 2024: pregnancy prevention programme required in women who could become pregnant). Doses per current BNF/SPC.

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

The Epley manoeuvre is an effective first-line treatment for posterior canal BPPV when performed by a trained clinician (Cochrane 2014; NICE CKS). Long-term vestibular suppressants (prochlorperazine, cinnarizine) are harmful in most vestibular conditions because they prevent central compensation — the brain's adaptive mechanism for recovering from labyrinthine dysfunction. They should be time-limited to the acute vomiting phase only. Evidence for betahistine in Ménière's is mixed — the Cochrane review (2016) found only low-quality evidence of benefit and the BEMED trial (BMJ 2016) found no reduction in attacks versus placebo; review at the agreed review point and stop if ineffective. Check doses and contraindications for betahistine, prochlorperazine and migraine prophylaxis against the current product information (BNF/SPC) and local ENT pathway. Vestibular rehabilitation physiotherapy improves outcomes across all peripheral vertigo conditions and is significantly under-prescribed in UK primary care.

Lifestyle

Non-Pharmacological Interventions — These Are Treatments

Done

Encourage regular sleep, hydration, smoking cessation, moderate alcohol intake and identification of individual triggers. Vestibular rehabilitation is useful for persistent imbalance. Dietary changes in Ménière's disease can be trialled, but evidence for specific salt, caffeine or alcohol thresholds is limited.

Vestibular Rehabilitation Exercises Cawthorne-Cooksey exercises or Brandt-Daroff exercises daily. Refer to vestibular physiotherapy if available. Useful for persistent imbalance.

Diet (Ménière's) Encourage a balanced diet and identification of individual triggers. Dietary changes can be trialled, but evidence for specific salt thresholds is limited — avoid excessive restriction.

Caffeine (Ménière's / VM) Reducing caffeine may be trialled if it appears to trigger attacks; evidence is limited.

Sleep hygiene (Vestibular Migraine) Consistent sleep times. Sleep disruption is a major vestibular migraine trigger. CBT-I referral if insomnia complicates.

Alcohol avoidance Moderate alcohol intake; reduce further if alcohol appears to trigger Ménière's or vestibular migraine attacks. Evidence for specific thresholds is limited.

Stress management Identify individual triggers, including stress. Mindfulness, CBT or relaxation techniques may help some patients.

Falls prevention Particularly for elderly patients. Home hazard assessment, removal of trip hazards, grab rails. Refer to falls clinic if recurrent falls. DVLA — patient must not drive during active vertigo episodes.

Driving advice (DVLA) Advise patients not to drive while vertigo, visual disturbance, imbalance or medication effects could impair control of a vehicle. DVLA notification depends on the diagnosis, severity, recurrence and effect on driving — direct the patient to current DVLA guidance and document the advice. The patient normally has the duty to notify; clinicians may need to notify DVLA if the patient cannot or will not and there is a significant road-safety risk.

Positional strategies (BPPV) Routine post-Epley restrictions (sleeping upright, avoiding head movements) are not needed. Gradually resume normal movements — avoidance behaviour worsens outcome.

Smoking cessation Advise smoking cessation. Refer to NHSE stop smoking service.

Central compensation — the brain's mechanism for recovering from unilateral vestibular loss — is dramatically accelerated by movement and exercise, and inhibited by immobility and vestibular suppressant drugs. Patients who stay in bed and take prochlorperazine long-term take weeks longer to recover than those who begin vestibular exercises. Driving advice must be discussed and documented, with reference to current DVLA guidance for the specific diagnosis and its effect on driving. Vertigo contributes to falls in older adults — active falls prevention is a safety intervention, not lifestyle advice.

Safety

Follow-Up, Monitoring & Safety-Netting

Done

Safety-net every patient — peripheral vertigo can relapse and central causes can evolve.

BPPV — within 1 month

Review Epley response. If not improved → check technique, consider contralateral ear. If symptoms persist despite correctly performed treatment, the diagnosis is uncertain or nystagmus is atypical → ENT referral. Self-Epley once the affected side is confirmed.

Vestibular Neuritis — 4–6 weeks

Review recovery. Refer vestibular physiotherapy if balance not improving. Stop prochlorperazine if still taking. Not improving as expected, or new neurological signs → reassess for a central cause; persistent significant symptoms → ENT or balance clinic (timing per local practice).

Ménière's — 8–12 weeks

Assess attack frequency and severity on betahistine. Confirm audiology appointment arranged. If not controlled → ENT referral.

Vestibular Migraine — 6–8 weeks

Review prophylaxis response. Migraine diary to track attacks. If not responding → neurology referral.

Medication review

At 4 weeks: ensure prochlorperazine stopped. Betahistine — review at the agreed review point; continue only if effective. Propranolol — titrate to response, check BP and HR.

Safety-net 999

New neurological symptoms (diplopia, dysarthria, facial weakness, limb weakness) · Sudden severe headache or new neck pain · New deafness with sudden continuous vertigo or other neurological symptoms · Unable to walk / truncal instability · Cardiac symptoms (chest pain, syncope)

Same-day GP / ED

Vertigo getting worse at any time, or vestibular neuritis not improving after 3–4 days · New ear pain, vesicles or facial weakness (Ramsay Hunt) · Falls with injury · Sudden or worsening hearing loss (ENT/ED within 24 h if ≤3 days, NICE NG98) · New atypical or central features

Recurrence warning

BPPV can recur — self-Epley if the affected side is confirmed. Ménière's is often long-term — reinforce avoidance of individual triggers. Document all vertigo consultations for medicolegal safety in central causes.

Posterior fossa strokes can present with initial apparent improvement followed by sudden deterioration ("stroke in evolution") — safety-netting for new neurological symptoms is essential even in patients discharged with a likely peripheral diagnosis. Vestibular neuritis typically improves significantly by 2–3 weeks; failure to improve should prompt re-evaluation for alternative diagnosis including acoustic neuroma or posterior fossa lesion. Documentation of safety-netting advice in the consultation note is essential — a medicolegal review of missed posterior fossa strokes consistently identifies absent documentation of neurological symptom advice as a key failure. Ménière's disease has significant mental health comorbidity (anxiety, depression) — specifically enquire at follow-up.