Dizziness and Vertigo: The Evidence Behind the Pathway

A 62-year-old retired teacher with diabetes and hypertension is brought to the emergency department at seven in the morning. He woke at four with the room spinning, and it has not stopped. He has vomited three times. He cannot walk to the toilet without holding the wall. The admitting note says “vertigo, ?BPPV, inj. promethazine given”. This is an illustrative case, not a real patient.

The Dizziness and Vertigo Pathway tells you what to do for him: which of four syndromes he has, which bedside test belongs to it, how to read that test, and when to image. What it no longer carries is most of the why: the history, the mechanisms and the study figures that used to sit in its Manoeuvres and Evidence tabs. They have moved here, so that the tool stays quick at the bedside. By the end of this article you will know why that admitting note asked the wrong question, and what the right one is.

1. Why “what do you mean by dizzy?” stopped being the first question

Most of us were taught to begin with the word. The old teaching sorted patients by the word they used: vertigo, presyncope, disequilibrium, lightheadedness. The word turns out to be unreliable: the same patient describes the same illness differently minutes apart, and stroke can produce any of the four.

For forty years the approach began by sorting the complaint into vertigo, presyncope, disequilibrium or lightheadedness. The classification fails at its first step. Patients change their own description within minutes when asked again. Ask our teacher twice and he may say “spinning” the first time and “giddy, as if I will fall” the second.

“Then should I stop asking what kind of dizziness it is?” Not entirely. The old taxonomy is still worth knowing, because examinations ask it and colleagues use it, and the words still carry some information once the timing has done the sorting. It is the wrong place to start, not a wrong idea. Start with timing and triggers instead (Newman-Toker 2015): is it continuous now, or does it come in episodes, and if episodes, what sets them off?

2. Four syndromes, and a test for each

Timing and triggers sort every dizzy patient into one of four syndromes, and each syndrome has its own short differential and its own bedside test. On a phone the tool now shows this as two narrow tables. Here it is whole.

Our teacher has been continuously dizzy for three hours, with vomiting and an unsteady gait. That is the acute vestibular syndrome. The admitting note reached for BPPV, benign paroxysmal positional vertigo, which belongs to the second row. This is the common mistake, and it is an easy one to make: a test borrowed from the wrong syndrome misleads. A Dix-Hallpike in continuous vertigo shows nystagmus whatever the cause.

3. HINTS: why the abnormal finding is the reassuring one

For the acute vestibular syndrome, the test is HINTS: Head Impulse, Nystagmus, Test of Skew. The first step confuses every student, so take it slowly.

The head impulse test reads the vestibulo-ocular reflex. Vestibular neuritis breaks the reflex on the affected side, so the eyes are dragged off target and a corrective saccade snaps them back. A stroke usually spares the reflex arc, so the eyes stay locked on target through a head this dizzy, and that normality is the alarm.

The vestibulo-ocular reflex is what keeps your eyes on a word while you shake your head. A saccade is a quick jump of the eyes. So when you turn our teacher’s head briskly and his eyes slip and then jump back, his vestibular nerve is not working on that side: a peripheral problem. If his eyes stay perfectly on your nose, the nerve is fine, and something else, higher up, is making him this dizzy.

“How good is it?” In the original cohort the three-step examination was 100 per cent sensitive and 96 per cent specific for stroke, and diffusion-weighted MRI within the first 48 hours missed about one stroke in eight that HINTS caught (Kattah 2009). Sensitivity is how many of the strokes it found. So at the bedside, in those hands, it did better than an early MRI.

“In those hands” is the catch. Those figures came from subspecialist examiners testing continuously symptomatic patients with visible nystagmus. That is why the 2023 GRACE-3 guideline, which the tool keeps, says that HINTS applies only during the acute vestibular syndrome with nystagmus present, that clinicians should be trained in it, and that in untrained hands it is not standard of care (Edlow 2023). If you have not practised it, the tool asks you to treat the examination as not done, and to fall back on gait: a patient who cannot stand or walk unaided is central until proved otherwise.

4. Positional vertigo is a mechanical disease

If HINTS is for the continuous patient, the Dix-Hallpike is for the patient whose attacks come with a change of head position. Why does a manoeuvre cure it, when tablets do not?

Otoconia dislodged from the utricle fall into a semicircular canal, most often the posterior because it is lowest, and turn a rotation sensor into a gravity sensor. Otoconia are tiny calcium carbonate crystals that normally sit in the utricle. Once loose in a canal, they roll when the head moves relative to gravity, and the canal reports a spin that is not happening. That explains the short delay before the nystagmus starts, while the debris gets moving; it explains why each attack lasts under a minute; and it explains why the treatment is a manoeuvre that rolls the crystals back out. A vestibular suppressant cannot move a crystal.

For a patient who wants to read about it in plain words, the site has a public article, Doctor, I Have Vertigo. What Can I Do Now?

5. The Canadian Syncope Risk Score: what it was built on

Some dizzy patients have fainted. The tool sends them down a different road, because a blackout is a circulation problem until proved otherwise, and it grades the risk with the Canadian Syncope Risk Score.

• The score: derived in 4,030 emergency department patients, spanning minus 3 to plus 11, predicting serious outcomes in the 30 days after disposition, from 0.4 per cent at the bottom of the range to 83.6 per cent at the top (Thiruganasambandamoorthy 2016).
• What actually predicts danger, from its nine items: the clinician’s own end-of-assessment impression, an abnormal troponin, an extreme systolic pressure and a QTc above 480 ms. A lifelong vasovagal pattern subtracts risk.

Read the second point again. One of the strongest items is your own judgement at the end of the assessment, written down as a score item. That is the score telling you that the examination still counts. It is also why the tool refuses to compute the score while the troponin or the ECG items are unentered: an unmeasured troponin scored as normal quietly understates the risk.

Back to the emergency department

Our teacher has the acute vestibular syndrome, not BPPV, so the Dix-Hallpike is the wrong test. If someone trained is on duty, HINTS is done while he still has nystagmus; any one dangerous answer, or new deafness on one side, points to stroke. If nobody trained is on duty, his inability to walk unaided is enough to treat him as central. A plain CT does not exclude a posterior fossa stroke, so the tool asks for MRI, knowing that it can be falsely normal in the first two days. The promethazine treats the nausea and nothing else. Each of those steps is a line in the tool. Now you know what stands behind each line.

Try this

A 45-year-old woman has had brief spells of spinning for a week, each lasting about 20 seconds, every time she lies down or turns over in bed. Between spells she is well and has no nystagmus. Is HINTS the test? Illustrative case.

Answer. No. Her attacks are triggered and brief, so she has the triggered episodic syndrome, and the test that belongs to it is the Dix-Hallpike, with the supine roll test if that is negative or shows horizontal nystagmus. HINTS between attacks shows nothing whatever the cause. If the Dix-Hallpike shows torsional up-beating nystagmus after a few seconds’ delay, she has posterior canal BPPV, and the Epley or the Semont manoeuvre is the treatment.

Take-home points

• Ask about timing and triggers first. The word the patient uses for the dizziness is unreliable.
• Each of the four syndromes has its own test. A test borrowed from the wrong syndrome misleads.
• In HINTS an abnormal head impulse is the reassuring finding, and only in a patient who is dizzy and has nystagmus as you test.
• If you have not been trained in HINTS, a patient who cannot walk unaided is central until proved otherwise.
• Positional vertigo is debris in a canal: the treatment is a manoeuvre, not a tablet.

Declaration: the author built and maintains the tool. It is free to use. The figures in this article are those the tool carried in its Manoeuvres and Evidence tabs on 4 November 2026, each from the source named beside it. The Dizziness and Vertigo Pathway is still in administrator preview, pending clinical review.

References

1. Newman-Toker DE, Edlow JA. TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol Clin. 2015;33(3):577-599.
2. Edlow JA, Carpenter C, Akhter M, et al. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023;30(5):442-486.
3. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-3510.
4. Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013;20(10):986-996.
5. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3 Suppl):S1-S47.
6. Strupp M, Bisdorff A, Furman J, et al. Acute unilateral vestibulopathy/vestibular neuritis: diagnostic criteria. Consensus document of the Bárány Society. J Vestib Res. 2022;32(5):389-406.
7. Lopez-Escamez JA, Carey J, Chung WH, et al. Diagnostic criteria for Menière’s disease. Consensus document of the Bárány Society and partner societies. J Vestib Res. 2015;25(1):1-7.
8. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: diagnostic criteria (update). J Vestib Res. 2022;32(1):1-6.
9. Staab JP, Eckhardt-Henn A, Horii A, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): consensus document of the Bárány Society. J Vestib Res. 2017;27(4):191-208.
10. Brignole M, Moya A, de Lange FJ, et al. 2018 ESC guidelines for the diagnosis and management of syncope. Eur Heart J. 2018;39(21):1883-1948.
11. Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ. 2016;188(12):E289-E298.
12. Freeman R, Wieling W, Axelrod FB, et al. Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clin Auton Res. 2011;21(2):69-72.
13. Dhiman NR, Joshi D, Gyanpuri V, Pathak A, Kumar A. Comparison between Epley and Gans repositioning maneuvers for posterior canal BPPV: a randomized controlled trial. Ann Indian Acad Neurol. 2023;26(4):537-542.
14. Deva FAL. Epley’s manoeuvre vs. Semont’s maneuver in post-canal benign paroxysmal positional vertigo: a comparative study in a tertiary centre. Indian J Otolaryngol Head Neck Surg. 2024;76(5):3854-3859.