Emergency Department Evaluation of Acute Dizziness
Practical guidelines for acute dizziness for otolaryngology residents and new attendings.
Edward I. Cho, MD, on behalf of the Equilibrium Committee
Consider this scenario: A 68-year-old man with hypertension and hyperlipidemia presents with vertigo, nausea, vomiting, and inability to stand for the past 12 hours. Brain MRI is negative. Neurology has evaluated the patient and concluded this is "peripheral vertigo—please consult ENT."
As the on-call otolaryngology resident or junior attending, what should you consider? What entities can you diagnose and treat as an inpatient? And isn't dizziness primarily an outpatient complaint for otolaryngologists anyway?
This scenario plays out countless times across emergency departments, highlighting fundamental questions about specialty roles in acute dizziness evaluation. Recent literature has sparked debate about whether every ER patient with vertigo needs specialist consultation.1 The arguments are compelling on both sides—two or three physicians examining a patient may be better than one, yet there are insufficient specialists to evaluate the approximately 4.8 million annual ER dizziness presentations in the United States alone.1
The critical question becomes: Is the average otolaryngology resident or attending better equipped than the average emergency physician for this evaluation? The answer is highly individual and depends on specific training and interest. However, to provide optimal patient care and prevent bad outcomes like falls and strokes, otolaryngologists must understand the broader evaluation framework.
The Modern Approach
The 2023 Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) represent a major collaborative effort from the emergency medicine community.2 These guidelines were developed through a consortium of emergency medicine organizations, including the Society for Academic Emergency Medicine, and involved systematic review of over 1,700 patients across 14 studies. For otolaryngologists who may be unfamiliar with developments in emergency medicine, GRACE-3 represents the current standard for ED evaluation of dizziness, replacing outdated approaches that relied on symptom quality ("spinning" versus "lightheaded") with a timing-and-triggers framework that has proven more diagnostically accurate.2
This framework transforms a bewildering differential into three manageable clinical syndromes:
Table 1. The three vestibular syndromes.
Original table based on information in Reference 2 below.
Acute vestibular syndrome presents as acute onset of continuous vertigo, nausea, vomiting, and gait instability lasting more than 24 hours. The primary differential diagnosis includes vestibular neuritis (inflammation of the vestibular nerve, presumed viral) and posterior circulation stroke (cerebellar or brainstem infarction). The diagnostic challenge lies in the fact that symptom severity provides no reliable differentiation—a devastating cerebellar stroke can present with symptoms identical to benign vestibular neuritis.3
The Head Impulse, Nystagmus, Test of Skew (HINTS) examination was first described by Newman-Toker et al. in 2009.4 A systematic review by Shah et al. found HINTS, when properly performed, has 92.9% sensitivity (95% CI 79.1%-97.9%) for detecting stroke—superior to MRI within the first 24-48 hours.5 However, proper training is essential: studies show six to eight hours of formal training plus 10-15 proctored examinations are needed for proficiency.6
Table 2. HINTS examination components.
Original table based on information in Shah et al 2023 in Reference 5 below.
It is critical to understand that HINTS is only valid in patients with ongoing continuous symptoms and spontaneous nystagmus.3 The examination should be carefully interpreted in patients with episodic symptoms or those who are asymptomatic at the time of evaluation.
Triggered Episodic Vestibular Syndrome
Triggered episodic vestibular syndrome accounts for approximately 30% of ED dizziness presentations and is characterized by brief episodes of vertigo triggered by specific head movements.2 Benign paroxysmal positional vertigo (BPPV) represents approximately 90% of triggered episodic cases, making it the most common cause of vertigo overall.2
Benign Paroxysmal Positional Vertigo
BPPV results from otoconia becoming dislodged from the utricle and migrating into the semicircular canals. The posterior canal is affected in approximately 90% of cases due to its dependent position.2 The Dix-Hallpike test remains the gold standard for diagnosis, with classic findings including:2
Latency of one to five seconds
Upbeat-torsional nystagmus
Duration less than 60 seconds
Fatigability with repeated testing
The Epley maneuver, performed immediately after positive Dix-Hallpike, has an 80%-90% success rate with single treatment.2
Central Paroxysmal Positional Vertigo
Central paroxysmal positional vertigo is much less common but critical to recognize. The differential diagnosis for central positional vertigo includes three main categories:
1. Posterior Fossa Mass Lesions
Cerebellar tumors
Arnold-Chiari malformations
2. Vascular Lesions
Cerebellar infarction
Vertebrobasilar insufficiency
3. Demyelinating Disease
Multiple sclerosis plaques in the brainstem or cerebellum
ADEM (Acute Disseminated Encephalomyelitis)
Red flags suggesting central positional vertigo include:3
Pure downbeating nystagmus (highly specific for central pathology)
Pure upbeating nystagmus
Purely torsional nystagmus
Direction-changing nystagmus while head is held in single position
Spontaneous episodic vestibular syndrome presents as recurrent episodes of vertigo without specific triggers, lasting minutes to hours. The differential diagnosis primarily includes vestibular migraine, Ménière’s disease, and transient ischemic attacks. Accurate diagnosis often requires detailed history-taking, as patients are frequently asymptomatic at the time of evaluation.
Vestibular Migraine
Vestibular migraine is now recognized as more common than Ménière’s disease and represents a significant cause of episodic vertigo.7 The International Classification of Headache Disorders (ICHD-3) criteria for vestibular migraine require:
Definite Vestibular Migraine:
At least five episodes of vestibular symptoms of moderate or severe intensity lasting five minutes to 72 hours
Current or previous history of migraine with or without aura
One or more migraine features with at least 50% of vestibular episodes:
Headache with at least two characteristics: unilateral, pulsating, moderate-severe intensity, aggravation by routine physical activity
Photophobia and phonophobia
Visual aura
Not better accounted for by another vestibular diagnosis
For outpatient management, otolaryngologists may consider migraine preventative medications (propranolol, topiramate, nortriptyline) and lifestyle modifications including trigger avoidance, sleep hygiene, and dietary changes. Acute episodes that require intravenous treatment, such as prochlorperazine or magnesium infusions, are typically managed by neurology based on general migraine literature, as vestibular migraine-specific evidence remains limited.
Two or more spontaneous episodes of vertigo lasting 20 minutes to 12 hours
Audiometrically documented low- to medium-frequency sensorineural hearing loss in the affected ear on at least one occasion
Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear
Not better accounted for by another vestibular diagnosis
Key diagnostic points:
Episodes lasting less than 20 minutes or more than 12 hours argue against Ménière’s and more for vestibular migraine
Early in the disease, hearing may return to normal between attacks
Late-stage disease shows permanent low-frequency hearing loss
Treatment includes salt restriction, diuretics, and betahistine where available. Intratympanic steroids or ablative procedures such as intratympanic gentamicin or surgeries may be considered for refractory cases.
Transient Ischemic Attack (TIA)
TIA must always be considered in spontaneous episodic syndrome, particularly in patients with vascular risk factors. Isolated vertigo can be the sole manifestation of vertebrobasilar TIA.9 Studies show that isolated vertigo is the most common premonitory symptom of posterior circulation stroke.⁹
Pattern of attacks (crescendo pattern suggests impending stroke)
Duration (typically minutes, rarely >1 hour)
Associated symptoms (even subtle diplopia, dysarthria, or weakness)
Any patient with suspected TIA requires urgent evaluation and consideration of antiplatelet therapy or anticoagulation based on etiology.
Imaging Limitations
Noncontrast head CT has pooled sensitivity of only 28.5% (range 6.7-75.0%) for posterior fossa stroke.10 Even MRI within 48 hours misses approximately 20% of strokes2. The implication is that clinical examination by trained providers often outperforms imaging. If history strongly suggests stroke but initial MRI is negative, consider repeat imaging after 48-72 hours.2
Conclusions
Emergency dizziness evaluation requires systematic thinking rather than encyclopedic knowledge. By categorizing patients into acute vestibular syndrome, triggered episodic vestibular syndrome, or spontaneous episodic vestibular syndrome, the differential diagnosis narrows considerably and guides appropriate examination. The GRACE-3 guidelines provide an evidence-based framework that has been validated across multiple emergency departments.
For otolaryngologists, understanding this framework is essential for several reasons. First, it allows for rapid identification of patients requiring urgent neuroimaging versus those who can be managed conservatively. Second, it provides a common language for communication with emergency medicine and neurology colleagues. Finally, it ensures that patients receive appropriate treatment in a timely manner.
Patients discharged with "peripheral vertigo" have a relative risk of stroke 9.3 times higher than matched controls at 30 days.11 This elevated risk underscores the importance of accurate diagnosis and appropriate follow-up. When uncertainty exists, especially with inability to walk or central findings, maintaining high suspicion for stroke is warranted. The consequences of missing posterior circulation stroke far outweigh the costs of additional evaluation.
Disclosures: This manuscript reflects the author's clinical experience in otolaryngology and vestibular medicine. Although generative AI technology was used to assist with literature synthesis and initial drafting, all clinical insights, diagnostic approaches, and treatment recommendations are based on the author's professional expertise and judgment. The author has thoroughly reviewed, verified, and substantially revised all content, ensuring accuracy and clinical relevance. The author takes full responsibility for the integrity of the work and all medical opinions expressed herein.
Acknowledgements: The author acknowledges Bruce L. Fetterman, MD, MBA for his valuable contributions in reviewing and providing editorial assistance during the final preparation of this manuscript.
References
Puissant MM, Giampalmo S, Wira CR, Goldstein JN, Newman-Toker DE. Approach to Acute Dizziness/Vertigo in the Emergency Department: Selected Controversies Regarding Specialty Consultation. Stroke. 2024;55(10):2584-2588. doi:10.1161/STROKEAHA.123.043406
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. doi:10.1111/acem.14728
Choi WY, Gold DR. Vestibular Disorders: Pearls and Pitfalls. Semin Neurol. 2019;39(06):761-774. doi:10.1055/s-0039-1698752
Newman-Toker DE, Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. H.I.N.T.S. to Diagnose Stroke in the Acute Vestibular Syndrome—Three-Step Bedside Oculomotor Exam More Sensitive than Early MRI DWI. Stroke J Cereb Circ. 2009;40(11):3504-3510. doi:10.1161/STROKEAHA.109.551234
Shah VP, Oliveira J. e Silva L, Farah W, et al. Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for GRACE-3. Acad Emerg Med. 2023;30(5):552-578. doi:10.1111/acem.14630
Vanni S, Pecci R, Edlow JA, et al. Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm. Front Neurol. 2017;8. doi:10.3389/fneur.2017.00590
Basura GJ, Adams ME, Monfared A, et al. Clinical Practice Guideline: Ménière’s Disease Executive Summary. Otolaryngol Neck Surg. 2020;162(4):415-434. doi:10.1177/0194599820909439
Paul NL, Simoni M, Rothwell PM. Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol. 2013;12(1):65-71. doi:10.1016/S1474-4422(12)70299-5
Shah VP, Oliveira J. e Silva L, Farah W, et al. Diagnostic accuracy of neuroimaging in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for the guidelines for reasonable and appropriate care in the emergency department. Acad Emerg Med. 2023;30(5):517-530. doi:10.1111/acem.14561
Atzema CL, Grewal K, Lu H, Kapral MK, Kulkarni G, Austin PC. Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol. 2016;79(1):32-41. doi:10.1002/ana.24521
Original table based on information in Reference 2 below.
Original table based on information in Shah et al 2023 in Reference 5 below.
Original table based on information in Shah et al 2023 in Reference 5 below.
