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Acute vertigo: getting the diagnosis right

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj-2021-069850 (Published 12 August 2022) Cite this as: BMJ 2022;378:e069850
  1. Kiran Agarwal, general practitioner1,
  2. James Harnett, consultant in emergency medicine2,
  3. Nishchay Mehta, consultant ENT surgeon3,
  4. Fiona Humphries, consultant in stroke medicine4,
  5. Diego Kaski, consultant neurologist5
  1. 1Ashlea Medical Practice, Surrey, UK
  2. 2Emergency Department, University College London Hospitals NHS Foundation Trust, London, UK
  3. 3University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
  4. 4Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
  5. 5Department of Clinical and Movement Neurosciences, University College London, UK
  1. Correspondence to: D Kaski d.kaski{at}ucl.ac.uk

What you need to know

  • All patients presenting with brief episodic acute vertigo or unsteadiness should undergo a Dix-Hallpike manoeuvre

  • Consider stroke in patients with new onset acute unilateral hearing loss and vertigo

  • Urgent brain imaging is always indicated when acute vertigo is accompanied by other central neurological signs (such as dysphagia, dysarthria, diplopia)

  • Severe acute gait ataxia (patient unable to stand without support) is most common with central causes of vertigo (such as cerebellar lesions) rather than inner ear causes

Dizziness is a common presentation to emergency departments and primary care.12 It is defined as the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion.3 The estimated prevalence of dizziness in a general practice community sample varies across studies4 but is approximately 20%.56 Its prevalence increases with age.

While patients often use the word “dizziness” to describe their symptoms, this encapsulates a variety of distinct symptom clusters, including vertigo (box 1). Vertigo is a specific type of dizziness defined as the sensation of self motion when no self motion is occurring or the sensation of distorted self motion during an otherwise normal head movement.3 Acute vertigo represents up to 5% of all admissions to the emergency department.7

Box 1

Specific definitions that are often included under the term “dizziness”

  • Dizziness—The sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion

  • Vertigo—The sensation of self motion when no self motion is occurring or the sensation of distorted self motion during an otherwise normal head movement

  • Light-headedness—A feeling you are “going to faint”

  • Imbalance—A state of being out of equilibrium, or with loss of balance

  • Gait disorder—A problem or difficulty with walking

  • Acute vestibular syndrome—Sudden onset of vertigo, nausea, postural instability, and nystagmus lasting for ≥24 hours

  • Transient vestibular syndrome—Sudden onset of …

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