Dizziness or vertigo

at the bedside

airway, breathing, circulation; full vitals, SpO₂, finger-prick glucose; sit them on the edge of the bed with a nurse beside them, nobody walks alone yet
what they mean by dizzy → the room spins (vertigo); lightheaded, about to faint, worse on sitting or standing (presyncope); unsteady on the feet with a clear head (imbalance); vague, with new confusion or drowsiness → altered mental status
timing → seconds, set off by turning in bed or looking up (positional); continuous for hours with nausea and nystagmus (acute vestibular syndrome: neuritis or stroke); minutes, out of the blue, settled by the time you arrive (episodic: think TIA before Meniere)
lying and standing BP → do it yourself if presyncope or imbalance; with HR; the criteria are in the send-now panel
can they walk → stand and take a few steps with support; cannot stand or sit unaided with the eyes open is a central sign until proven otherwise
chart and MAR → why admitted; a new or increased antihypertensive, diuretic, nitrate, alpha-blocker, sedative, opioid, anticonvulsant, antiemetic; aminoglycoside or vancomycin; insulin or a sulfonylurea; anticoagulant; fluid balance and today’s hemoglobin
if they fell with it → injury first, head strike and anticoagulation set the CT decision → falls, syncope: injury

escalate now if

vertigo with any central sign → new diplopia, dysarthria, dysphagia, facial or limb weakness or numbness, limb ataxia, severe gait ataxia or cannot stand, vertical or direction-changing nystagmus, skew deviation → posterior circulation stroke until proven otherwise: note last known well → stroke pathway, neurology now
continuous vertigo with nystagmus and a normal head impulse test, or HINTS you cannot do confidently → treat as central: the same pathway, do not wait for the morning MRI
new severe headache or neck pain with vertigo, or vomiting with drowsiness, with a lower threshold on an anticoagulant → cerebellar hemorrhage or vertebral artery dissection → CT head and CT angiography now → hemorrhage, headache
presyncope with an abnormal rhythm, chest pain, dyspnea or hypotension → monitor and 12-lead ECG now → syncope, tachycardia, bradycardia, hypotension
low glucose on the finger-prick → treat now, the dizziness waits → hypoglycemia
new confusion, drowsiness or a fluctuating level of attention → not a vestibular problem → altered mental status, delirium
SpO₂ below target, melena or a hemoglobin drop → oxygen desaturation, hemoglobin drop

differentials

vertigo: the room moves

peripheral → BPPV (seconds, positional, fatigues on repeat testing; common after days lying in bed); vestibular neuritis (continuous for days, nausea, unidirectional horizontal nystagmus, walks with support, hearing intact); Meniere (minutes to hours with one-sided hearing loss, tinnitus, fullness); drug ototoxicity (aminoglycoside, vancomycin, loop diuretic, cisplatin: imbalance more than spinning)
central → posterior circulation stroke or TIA (vascular risk, atrial fibrillation, any escalate sign); cerebellar hemorrhage (headache, vomiting, cannot stand, anticoagulant); vertebral artery dissection (neck pain, recent neck manipulation or trauma, younger patient); less often multiple sclerosis, posterior fossa tumor, Wernicke encephalopathy

lightheaded: about to faint

orthostatic → volume (poor intake, vomiting, diarrhea, diuretics, bleeding), drugs (antihypertensives, nitrates, alpha-blockers, tricyclics, antipsychotics, levodopa), autonomic failure (diabetes, Parkinson disease, days of bed rest)
cardiac → brady- or tachyarrhythmia, aortic stenosis, heart failure, ACS, PE → syncope, palpitations
metabolic → hypoglycemia, hyponatremia, anemia, hypoxia, hypercapnia, sepsis, dehydration, uremia

unsteady, or something else

medication → sedatives and benzodiazepines, opioids, anticonvulsants (phenytoin, carbamazepine: nystagmus and ataxia at toxic levels), antihistamines, gabapentinoids, anticholinergics, a new antihypertensive; alcohol or sedative withdrawal
imbalance without vertigo → peripheral neuropathy, deconditioning after days in bed, visual loss, cerebellar disease, normal pressure hydrocephalus; a new focal pattern → neurological deficit
psychogenic or functional → constant floating or rocking with anxiety, normal exam and gait; a treating-team diagnosis once organic causes are excluded, not an overnight label

focused check

timing and triggers → seconds with a head movement = BPPV; continuous for hours to days = neuritis versus stroke; spontaneous episodes lasting minutes = TIA until proven otherwise; ask about hearing change, tinnitus, headache, neck pain, recent viral illness, a fall or neck manipulation
vascular risk → age, hypertension, diabetes, atrial fibrillation, previous stroke or TIA, smoking, anticoagulant held for a procedure; any of these lowers the bar for the stroke pathway
neurological exam → eye movements and nystagmus in primary gaze and lateral gaze; cranial nerves, facial and limb power and sensation, finger-nose and heel-shin, speech, visual fields; then gait with support: cannot sit or stand unaided is central
Dix-Hallpike → only for brief positional episodes with no spontaneous nystagmus and a normal neurological exam; positive = torsional upbeating nystagmus after a few seconds’ delay, lasting under a minute, fatiguing on repeat; caution with cervical spine disease or recent neck surgery; a negative test with an ongoing story is not reassuring
HINTS → only in continuous vertigo with spontaneous nystagmus, and only if you have been taught it: head impulse (a corrective saccade after a quick head turn = peripheral; a normal, smooth head impulse in a patient this dizzy = stroke sign), nystagmus (changes direction with gaze, or vertical = central), test of skew (vertical misalignment on cover-uncover = central); any one central finding, or no confidence in the test, puts the patient on the stroke pathway
hearing → finger rub at each ear: new one-sided hearing loss with continuous vertigo counts as central (anterior inferior cerebellar artery territory) until imaged, not Meniere; long-standing fluctuating loss with episodes fits Meniere for the treating team
exam for the lightheaded → pulse rate and regularity, murmur, JVP, hydration, pallor, melena if bleeding is possible

send now

nothing routinely → classic BPPV with a positive Dix-Hallpike, a normal neurological exam and a safe gait: no bloods or imaging tonight; treat at the bedside and document
presyncope or imbalance → 12-lead ECG; orthostatic BP → after ≥ 5 min lying, measure within 3 min of standing; positive if SBP drops ≥ 20 or DBP ≥ 10 mmHg (SBP ≥ 30 if supine hypertension); a positive test does not exclude a cardiac cause → syncope
lightheaded or unsteady → glucose if not done; CBC, RFT and sodium, Mg; drug levels if on phenytoin, carbamazepine, lithium or digoxin; troponin only if chest pain, ischemic ECG or possible myocardial injury without pain → sodium, hemoglobin drop, troponin
central cause suspected → MRI brain with DWI is the test, arranged with neurology; CT is poor for the posterior fossa and a normal CT excludes nothing; early MRI can miss a small brainstem or cerebellar stroke in the first 48 h, so a central exam stays central whatever the scan says
CT head and CT angiography tonight → new headache or neck pain, drowsy or vomiting (hemorrhage, dissection), within a reperfusion window, or a central pattern when MRI is not available tonight; an anticoagulant lowers the threshold but is not an indication on its own: image by the suspected cause and the neurological findings → neurological deficit
telemetry → presyncope with palpitations, an abnormal ECG, structural heart disease or no prodrome; gas → only if hypoxemic, drowsy or at risk of hypercapnia → venous blood gas
not tonight → audiometry, vestibular testing, echo for a soft murmur with a normal ECG: treating team, ENT or cardiology by day

treat

central cause suspected

stroke pathway now: last known well, glucose, BP, NIHSS, neurology on the phone; a posterior circulation stroke is a thrombolysis and thrombectomy call like any other, and the window runs from last known well → ischemic stroke
hemorrhage on CT, or cannot stand with headache and vomiting → cerebellar hemorrhage compresses the brainstem fast: neurosurgery and ICU now → hemorrhage
nil by mouth until a swallow screen; bed rest; no vestibular suppressant that blurs the exam before neurology has seen the patient; anticoagulant and antiplatelet decisions belong to the stroke pathway → anticoagulation

BPPV: positive Dix-Hallpike, nothing central

Epley maneuver at the bedside for the affected side, repeated once if still positive; it is the treatment, do it tonight rather than medicate (AAO-HNS 2017)
no vestibular suppressant, no imaging and no bloods for BPPV alone; they add sedation and falls without shortening the episode
warn that mild unsteadiness can follow for a day; mobilize with help; falls precautions → falls
Epley not working, atypical nystagmus (downbeating, pure vertical, no delay, does not fatigue), or any central feature → back to central cause; ENT or neurology by day

vestibular neuritis: continuous vertigo, peripheral HINTS, can walk with support

a diagnosis of exclusion at night: the HINTS exam must be peripheral on all three parts, hearing intact, no other neurology; if in doubt it is central until the MRI
nausea and spinning → cyclizine 50 mg PO/IM/slow IV TDS, anticholinergic: caution in the elderly, glaucoma, prostatic enlargement, heart failure; or ondansetron 4–8 mg IV/PO up to TDS, check the QTc first if long QT, heart failure, low K or Mg, or other QT drugs; full antiemetic table → nausea and vomiting
vestibular suppressant → the shortest course that lets them eat and sleep, stopped once walking: it delays central compensation; a benzodiazepine for vertigo is a treating-team decision, not an overnight start
IV fluids if vomiting and dry → nausea and vomiting; early mobilization with help from the next morning, it is the rehabilitation
steroids → an option in confirmed neuritis (GRACE-3 2023), decided with neurology or ENT by day; not an overnight order

presyncope and orthostatic dizziness

lie flat, legs raised; positive orthostatics or dry → fluids, which drugs to hold tonight by BP and indication, how to mobilize → syncope: orthostatic
BP that stays low after fluids, or a shock picture → hypotension; bleeding or a hemoglobin drop → syncope: bleeding
an arrhythmia on the ECG or monitor, or presyncope with no prodrome → cardiac syncope, cardiology tonight
a true faint, however brief → the whole syncope sheet applies

drug review

started or increased this admission → antihypertensive, diuretic, nitrate, alpha-blocker, sedative, opioid, antihistamine, gabapentinoid, anticonvulsant: a decision per drug by its indication, tonight’s BP and the exam, not an automatic hold; hold tonight only what is likely contributing and not needed before the morning review, document which and why; do not stop a chronic benzodiazepine, baclofen or opioid abruptly, taper with the treating team
levels → phenytoin or carbamazepine with nystagmus and ataxia, lithium, digoxin: level tonight, hold the next dose until it is back; aminoglycoside or vancomycin with new imbalance or hearing change: level, tell the treating team
insulin or sulfonylurea → glucose now and before the next dose → hypoglycemia
anticoagulant → dizzy with headache, neck pain or a head strike changes the imaging threshold, not the drug: the scan decides → anticoagulation

keep them off the floor

bed low, call bell in reach, commode or bedpan rather than a walk to the bathroom tonight, mobilize only with a nurse until reviewed
document the gait you saw and who may walk them; falls risk and the injury check if they already fell → falls

reassess

when → within the hour after an Epley, an antiemetic or a fluid bolus, then with each set of vitals
what → the neurological exam again (new nystagmus pattern, diplopia, dysarthria, limb ataxia, a worse gait), BP and HR lying and standing, glucose if it was low, vomiting and oral intake, telemetry if running
not settling → vertigo still continuous at the next round, any new central sign, a second presyncopal episode, or BP that stays low → back to the escalate box; a peripheral label never survives a new central sign

hand over → which kind of dizzy and the working cause, HINTS or Dix-Hallpike findings, gait and mobility order, orthostatics and ECG, drugs held and levels pending, imaging done or requested, neurology or ENT review needed, escalation trigger

evidence

source	type
Bhattacharyya et al. 2017 · Benign paroxysmal positional vertigo, clinical practice guideline update (AAO-HNS) ↗︎	specialty-society guideline
Edlow et al. 2023 · GRACE-3: acute dizziness and vertigo (SAEM) ↗︎	specialty-society guideline
Kattah et al. 2009 · HINTS to diagnose stroke in the acute vestibular syndrome (Stroke) ↗︎	diagnostic accuracy study
Tarnutzer et al. 2011 · Does my dizzy patient have a stroke? Bedside diagnosis in acute vestibular syndrome (CMAJ) ↗︎	systematic review
Saber Tehrani et al. 2014 · Small strokes causing severe vertigo: early MRI false negatives (Neurology) ↗︎	cohort study
AHA/ASA 2019 · Early management of acute ischemic stroke, 2019 update ↗︎	international guideline
Freeman et al. 2011 · Consensus definition of orthostatic hypotension (American Autonomic Society / AAN) ↗︎	consensus statement

Verify indication, dose, allergies, interactions, renal/hepatic function and local protocols before prescribing.

go deeper MOC+ Vol 3 · Acute Neurology covers this in the full reference, or the complete set.

free the on-call checklist covers the whole shift on one printable page.

studying for the IM exam? the IM Rapid Review covers this in the same format. see the sample chapter.

updated Oct 2026file complaint/dizziness