Work it through

Pattern-recognition pearls

The same handful of discriminators decide most of the cases. Learn these and the differential collapses from “everything” to a short, ranked list.

Separating dangerous from benign

  • In the acute vestibular syndrome, a normal head impulse, direction-changing nystagmus, or skew is the dangerous (central) HINTS pattern — image for stroke.1
  • Gait failure out of proportion to the vertigo — unable to stand or walk unaided — is a central red flag.
  • A normal head impulse in a genuinely vertiginous patient argues for, not against, a central cause.
  • Ask timing and triggers, not what the dizziness “feels like.”2

Sorting the episodic vertigos

  • Seconds, positional, fatigable → BPPV; diagnosed and cured at the bedside with positional testing and repositioning.3,4
  • Hours, with fluctuating hearing loss, fullness and tinnitus → Ménière’s — let serial audiometry confirm it.5
  • Variable duration, migrainous features, normal tests → vestibular migraine; headache may be absent in a given attack.6

Reading the chronic syndromes

  • Persistent dizziness worsened by upright posture, motion and busy visual scenes → PPPD.7
  • Persistent rocking relieved by passive motion (driving) → MdDS — the opposite of PPPD.8
  • Oscillopsia and imbalance worse in the dark, bilaterally abnormal head impulses → bilateral vestibulopathy.9
  • In an older adult, dizziness is usually multifactorial — find the modifiable parts; recognise presbyvestibulopathy but don’t stop there.10

Threads that run through every case

  • Vestibular suppressants are for days, not months — beyond the acute phase they impede compensation.
  • Vestibular rehabilitation is the shared therapy — across neuritis, central lesions, PPPD, bilateral loss and the older adult.11
  • Some causes are treatable and time-critical — stroke, AIED, bacterial labyrinthitis — so act before the window closes.
  • The team beats the individual — the right hand-off often matters more than the cleverest single clinician.

Key points

  • HINTS, gait, and timing/triggers separate dangerous from benign at the front door.
  • Duration and cochlear features sort the episodic vertigos.
  • Provocation vs relief by motion distinguishes PPPD from MdDS.
  • Time-limit suppressants; rehabilitate; and use the team.