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Dizziness and vertigo

Key sources
The following summarized guidelines for the evaluation and management of dizziness and vertigo are prepared by our editorial team based on guidelines from the Society for Academic Emergency Medicine (SAEM 2023), the European Society for Vascular Surgery (ESVS 2023), the American Physical Therapy Association (APTA 2022), the United States Department of Defense (DoD/VA 2021; 2016), the American College of Radiology (ACR 2018), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2017), the American Academy of Neurology (AAN 2017), and the Living Concussion Guidelines (LCG 2017).


1.Diagnostic investigations

Oculomotor assessment
Obtain routine three-component head impulse-nystagmus-test of skew examination by clinicians trained in its use to distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses in adult patients with acute vestibular syndrome with nystagmus presenting to the emergency department.
Consider eliciting a detailed history and performing a physical examination with emphasis on cranial nerves, including visual fields, eye movements, limb coordination, and gait assessment, to help distinguish between central (TIA) and peripheral (vestibular migraine, Ménière's disease) diagnoses in adult patients with spontaneous episodic vestibular syndrome presenting to the emergency department.
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More topics in this section

  • Hearing assessment

  • Gait assessment

  • Dix-Hallpike maneuver

  • Supine roll test

  • Vestibular function testing

  • Diagnostic imaging (acute vestibular syndrome)

  • Diagnostic imaging (episodic vestibular syndrome)

  • Diagnostic imaging (persistent vertigo)

  • Diagnostic imaging (benign paroxysmal positional vertigo)

2.Medical management

Management of benign paroxysmal positional vertigo: as per SAEM 2023 guidelines, perform the Epley canalith repositioning maneuver at the time of diagnosis of posterior canal benign paroxysmal positional vertigo in adult patients diagnosed by a positiveDix-Hallpike test.

More topics in this section

  • Management of vestibular neuritis

3.Specific circumstances

Patients with post-concussion vestibular dysfunction, acute mild traumatic brain injury, LCG: perform theDix-Hallpike maneuver for assessment of patients with symptoms of benign positional vertigo once the cervical spine has been cleared.
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More topics in this section

  • Patients with post-concussion vestibular dysfunction (post-acute mTBI)

4.Follow-up and surveillance

Vestibular rehabilitation: as per APTA 2022 guidelines, offer vestibular physical therapy in patients with acute, subacute, or chronic unilateral vestibular hypofunction.
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5.Quality improvement

Health professional training: ensure that emergency department clinicians receive training in bedside physical examination techniques for acute vestibular syndrome (head impulse-nystagmus-test of skew) and diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo Dix-Hallpike test and Epley maneuver).