Foundational Emergency Medicine Card · Adult

Approach to Dizziness in the ED

Timing and triggers beat symptom labels. Identify the syndrome, examine the eyes and gait, and image for a defined concern. Do not use HINTS as a screening test for every dizzy patient.

Updated July 2026Population AdultsRead time 3 min
3 patterns
continuous, spontaneous episodic, triggered episodic
HINTS+
trained examiner + true AVS with nystagmus
Walk them
gait is a core neurologic test
1
Sick or not?

Stabilize first and search for dangerous nonvestibular causes

  • ABCs, glucose, vitals, cardiac rhythm, last known well, and focused stroke screen
  • Ask about syncope, chest pain, dyspnea, palpitations, bleeding, pregnancy, intoxication, medication change, headache, neck pain, hearing loss, diplopia, dysarthria, weakness, numbness, or inability to walk
  • Examine mental status, cranial nerves, visual fields, pupils, eye movements, limb coordination, strength, sensation, cardiac findings, and gait when safe
  • Consider ECG for unexplained episodic lightheadedness, syncope, cardiac symptoms, older age, or dysrhythmia risk
Do not anchor on vertigo. Dizziness may represent stroke, hemorrhage, ACS, dysrhythmia, dissection, PE, anemia, sepsis, hypoglycemia, toxicologic disease, pregnancy complication, or medication effect.
2
Which syndrome?

Classify by timing and triggers, not by “vertigo” versus “lightheadedness”

Acute vestibular syndrome

Acute onset, persistent continuous dizziness, usually lasting days, with nausea, head-motion intolerance, gait unsteadiness, and often spontaneous nystagmus. Think vestibular neuritis versus posterior circulation stroke.

Spontaneous episodic

Discrete attacks without a clear trigger. Think TIA, vestibular migraine, Ménière disease, panic, arrhythmia, or hypoglycemia.

Triggered episodic

Brief attacks reproducibly provoked by position or standing, with normal baseline between episodes. Think BPPV or orthostatic hypotension. A movement that worsens continuous symptoms is not a trigger.

Clarify the trigger: Did the action start a brief episode from baseline, or merely worsen dizziness that was already present?

3
Which bedside exam fits?

Match the maneuver to the syndrome

Acute vestibular syndrome

  • Look for spontaneous nystagmus and test gait or truncal stability
  • If spontaneous nystagmus is present and you are trained, perform HINTS+: head impulse, nystagmus, test of skew, plus bedside hearing
  • Central or equivocal: normal head impulse, direction-changing or vertical/torsional nystagmus, skew, or new unilateral hearing loss
  • Without nystagmus, do not force HINTS. Use the full neurologic exam and severity of gait unsteadiness

Triggered episodic syndrome

  • Use Dix-Hallpike for suspected posterior-canal BPPV
  • Typical response: brief latency, transient upbeat-torsional nystagmus, fatigability, and reproduction of symptoms
  • Horizontal or atypical positional nystagmus needs a different pathway, such as supine roll testing or specialist assessment
  • Use orthostatic vitals when symptoms are linked to standing and the result will affect management
Hard stop

HINTS is not for intermittent symptoms, positional BPPV, resolved dizziness, or patients without an acute vestibular syndrome.

It is only reliable when used in the correct syndrome by a clinician trained in eye-movement examination. A central or equivocal result requires stroke evaluation and confirmatory imaging.

4
Which tests and treatment?

Test for a reason. Treat the defined syndrome

Imaging and labs

  • Noncontrast CT is poor for ruling out posterior ischemic stroke and should not be routine for isolated dizziness
  • CT remains appropriate for suspected hemorrhage, trauma, mass effect, or another CT-defined emergency
  • Use CTA or MRA when TIA, dissection, basilar or vertebrobasilar disease, or another vascular lesion is a real concern
  • Use MRI with DWI for central or equivocal HINTS, focal neurologic findings, severe unexplained gait impairment, or persistent central concern
  • Early MRI can miss posterior circulation infarction. Reassess the patient and do not let a negative early study override a concerning syndrome or exam
  • Order labs only for a supported alternative diagnosis: anemia, electrolyte disorder, infection, pregnancy, endocrine disease, intoxication, or drug effect

Symptom-directed treatment

Posterior-canal BPPV: perform the Epley maneuver. Avoid replacing repositioning with meclizine alone.
Vestibular neuritis: short-course vestibular suppressants and antiemetics may help during the first 24 to 72 hours. Prolonged use can delay central compensation. Discuss short-term steroids within 3 days; evidence is low certainty.
Vestibular migraine: treat the migraine phenotype and exclude central disease when the presentation is new, atypical, or high risk.
Central concern: activate the stroke pathway. Dizziness with disabling gait or other posterior circulation deficits may qualify for reperfusion based on time, imaging, and institutional protocol.
5
What disposition?

Disposition follows the syndrome, exam, gait, and diagnostic confidence

Discharge

  • Defined peripheral or benign nonvestibular diagnosis
  • Independent safe gait or return to functional baseline
  • Symptoms controlled and oral intake adequate
  • No concerning neurologic, cardiac, vascular, infectious, or metabolic findings
  • Clear instructions for Epley, medication duration, follow-up, and return precautions

Observe, admit, or consult

  • Central or equivocal HINTS, focal deficit, new hearing loss with AVS, severe truncal or gait instability, or inability to walk
  • High-risk spontaneous episodes concerning for TIA
  • Persistent vomiting, dehydration, uncontrolled symptoms, recurrent syncope, or dysrhythmia concern
  • Negative early imaging but persistent concern for posterior circulation stroke
  • Uncertain diagnosis with unsafe function, poor follow-up, or unreliable reassessment

Return now for: new weakness or numbness, double vision, trouble speaking or swallowing, severe headache or neck pain, fainting, chest pain, new hearing loss, inability to walk, persistent vomiting, or worsening symptoms.