Differential & action
Differential pathways
Ten conditions account for almost all the cases the ED sees. Recognising the one you have — and the one you must not miss — is the work this page supports.
Most acutely dizzy patients have a small set of conditions: BPPV (the commonest), vestibular neuritis, vestibular migraine, Ménière's, and the rare but devastating posterior-circulation stroke. Each has a different bedside picture and a different action.
The cards below pair each condition's clinical picture with the decisive evidence, the first-hour management, and the disposition rule of thumb. Filter by syndrome to focus on one TiTrATE branch at a time.
Vestibular neuritis presents as AVS with a peripheral HINTS pattern.1 The decisive central differential is posterior-circulation stroke, which the HINTS battery separates with high sensitivity in trained hands.2
Posterior-canal BPPV — the commonest single cause of vertigo across all ages — is recognised on Dix-Hallpike and treated with the Epley at the bedside.3Vestibular migraine is recognised by Bárány Society criteria and is treated as migraine, not as vestibular disease.4
The vascular differential is dominated by vertebrobasilar disease — atherosclerotic, embolic, and dissection — for which the NEJM review by Savitz and Caplan is the standard reference.5 Small posterior-fossa infarcts produce vertigo identical to neuritis at presentation and are MR-occult in 12–20% of cases in the first 24–48 hours.6
The disposition column on each card encodes the safety floor: any central feature admits; clean peripheral with safe mobilisation discharges. The disposition page walks the full rule set; the AVS Decision Tool applies it live.
Condition cards
Each card is sorted by urgency — emergent (red), urgent (amber), routine (green). Filter by TiTrATE branch to focus on one syndrome at a time.
Sudden, sustained vertigo with horizontal-torsional nystagmus that obeys Alexander's law, gait deviation toward the affected side, no hearing loss.
Peripheral HINTS: abnormal head impulse on the affected side, unidirectional nystagmus, absent skew.
Antiemetic; short course of methylprednisolone (taper from 100 mg) accepted but contested; early vestibular rehabilitation; do not prescribe long-term vestibular suppressants.
Discharge home if able to mobilise and tolerate fluids; outpatient vestibular physiotherapy within 72 h. Reassess at 1 week.
Acute vertigo identical to neuritis on first inspection. Subtle clues: normal head impulse, direction-changing nystagmus, vertical skew, truncal ataxia disproportionate to vertigo, hearing loss in AICA territory.
Central HINTS (normal HIT, direction-changing nystagmus, or skew); confirmation with MRI–DWI within 48 h (false-negative rate 12–20% in first 24 h).
Activate stroke pathway. Establish IV access; check glucose; obtain ECG, basic labs; non-contrast CT for haemorrhage; aspirin or thrombolysis per stroke-team protocol within the time window.
Admit to stroke unit. Posterior-circulation involvement is high-risk for malignant oedema; neurosurgical review for cerebellar infarct if mass effect.
Brief (< 1 min) attacks of vertigo triggered by lying back, rolling over or looking up. Nystagmus torsional-upbeat on Dix-Hallpike with latency, crescendo–decrescendo, and fatigue.
Positive Dix-Hallpike on the affected side, classical nystagmus.
Epley canalith-repositioning manoeuvre at the bedside. No imaging needed.
Discharge with post-Epley instructions and a one-week follow-up. Refer for outpatient repeat if persistent.
Brief positional vertigo triggered by head turns in the supine position. Horizontal nystagmus on supine roll: geotropic (canalithiasis) or apogeotropic (cupulolithiasis).
Positive supine roll test with horizontal nystagmus; lateralise by stronger response (geotropic) or weaker side (apogeotropic).
Lempert (barbecue) roll or Gufoni manoeuvre according to subtype. Forced prolonged position for refractory cupulolithiasis.
Discharge with rotational restrictions; outpatient follow-up at 1 week.
Recurrent episodes of vertigo lasting 5 min to 72 h, with current or prior migraine history. Often accompanied by photo-/phonophobia or visual aura. Examination usually normal between episodes.
Bárány Society criteria: ≥5 episodes of vestibular symptoms, with migraine features in ≥50% of attacks, and a personal/family history of migraine.
Migraine-style abortive therapy (NSAID, triptan, antiemetic). Reassurance. Do not start preventive therapy in the ED.
Discharge with migraine-diary, neurology / vestibular-clinic follow-up. Lifestyle and trigger advice.
Spontaneous episode of vertigo 20 min to 12 h, with fluctuating low-frequency sensorineural hearing loss, tinnitus and aural fullness.
Bárány Society diagnostic criteria. Audiometric documentation of low-frequency loss when accessible.
Antiemetic; antihistamine; consider a single dose of vestibular suppressant for severe attacks. Do not commit to long-term suppressant in the ED.
Discharge with otolaryngology follow-up for diagnosis confirmation, audiogram and long-term diet / diuretic plan.
Acute, sustained vertigo with concurrent hearing loss. Often follows upper respiratory infection or otitis media.
Acute vestibular syndrome with hearing loss; audiogram confirms sensorineural component; otoscopy may show middle-ear disease.
Antiemetic; consider IV antibiotics if bacterial source (otitis); corticosteroid; ENT urgent review. Watch for intracranial complications.
Admit or observe if hearing loss is severe or systemic infection suspected; otherwise discharge with ENT follow-up within 48–72 h.
Acute vertigo with simultaneous sudden hearing loss in one ear. Important AICA-stroke red flag in the patient with vascular risk factors.
Audiogram showing ≥30 dB loss across 3 contiguous frequencies; HINTS exam to triage vs central; consider MRI of internal auditory canal and posterior fossa.
High-dose oral corticosteroid taper started within 14 days improves outcome; consider intratympanic steroid as adjunct or salvage.
Admit if AICA stroke suspected; otherwise urgent ENT outpatient with audiometric monitoring.
Recurrent brief episodes of vertigo with associated brainstem or cerebellar symptoms (diplopia, dysarthria, weakness, numbness, dysphagia). Resolved on assessment.
History of associated focal neurological symptoms; ABCD² score for risk; MRI–DWI may capture interval infarct; carotid/vertebral imaging for source.
Stroke pathway. Aspirin 300 mg; consider dual antiplatelet for high-risk minor stroke/TIA per local protocol; admission for accelerated work-up.
Admit for TIA work-up; urgent neurology and vascular review.
Acute confusion, ataxia and ocular signs (bilateral horizontal gaze palsy, gaze-evoked nystagmus, ophthalmoplegia) in an at-risk patient (alcoholism, malnutrition, hyperemesis, post-bariatric).
Clinical syndrome in an at-risk patient; do not wait for thiamine level. MRI may show periaqueductal grey or mamillary body signal change.
Empirical IV thiamine 500 mg three times daily before glucose. Treat dehydration; replace electrolytes; admit.
Admit. Repeat thiamine through 72 h; neurology review; nutritional rehabilitation.