Primary Care Guidelines – Vertigo/Dizziness

 Vertigo is defined as an illusion of movement

 Explore characteristics of symptoms; examine for nystagmus
 Do a Hallpike test in all patients presenting with vertigo/dizziness
 At every stage, explore ‘Red Flags’ and refer as necessary
 Dizziness with pre-syncopal symptoms should be referred to Cardiology Refer to ENT/AVM if:
 Only the common causes of vertigo are included o Any other
Diagnosis: BPPV nystagmus
Click here for Hallpike Rx Epley, if o No recovery after 2
Patient attends with positional test and nystagmus Epleys
vertigo/dizziness Epley demonstration consistent with
Posterior canal
Vertigo lasting < Hallpike positive BPPV (up-
1 min and beating Consider Menière’s disease if
triggered by rotational vertigo lasts <24 hours.
Hallpike negative geotropic) (1)
changes in head Start Betahistine 16 mg mg
position tds and refer to ENT/AVM
Yes
Is the vertigo Yes Recurrent
associated with attacks?
Vertigo lasting unilateral Yes Consider Labyrinthitis (2)
20 minutes or hearing
more loss/tinnitus?
No Consider Start vestibular suppressants
Vestibular Neuritis for up to 72 hours e.g
(3) prochlorperazine 5-10mg tds.
Refer to ENT/AVM if no
better after 4 weeks
Episodic Vertigo Consider
Explore migraine Vestibular
lasting seconds Try dietary avoidance. If no
triggers/features migraine (4)
to hours
improvement, consider
prophylaxis
o Consider multisensory factors in elderly eg pizotifen 0.5mg - 1.5mg
Dizziness/
(5) on. If no better refer
imbalance
o Uncompensated peripheral vestibular AVM/Neurology
provoked by
impairment (6)
general
o Bilateral vestibular failure: oscillopsia (7)
movement
with head movement Refer to ENT/AVM for
o Central vestibular (see Red Flags) aetiology and management

1. The nystagmus beats upwards torwards the ceiling and is torsional RED FLAGS
(rotational) to the undermost ear (in the Hallpike postion). See video o First attack of vertigo with acute severe headache
link. To be added (refer to A/E – r/o CVA)
2. If sudden onset of significant unilateral hearing loss: consider o Persistent symptoms for > 1 month (refer to
steroids 60mg daily for 6 days. MRI may be required. Best option is ENT/AVM)
same day referral to ENT. o Nystagmus lasting > 48 hours (refer to ENT/AVM)
3. Consider vestibular migraine if vestibular neuritis appears recurrent o Unilateral tinnitus/dyascusis/aural fullness (follow
(more than 3 episodes) tinnitus pathway)
4. Vestibular migraine may present without headaches. May be o Sudden/fluctuating hearing loss (follow hearing
associated with bilateral tinnitus, aural fullness and muffled hearing. loss pathway)
Can mimic Menière’s disease. Refer to AVM/ENT if unsure. o Dysconjugate eye movements (refer to Neurology)
5. If falls are a significant feature, consider the Falls Clinic/Care of the o Posterior circulation symptoms (refer to
Elderly. Neurology)
6. Stop prochlorperazine and cinnarizine. Explore psychological factors o Positive Hallpike Test, provoking nystagmus but no
in chronically dizzy patients. symptoms (refer to AVM/Neurology)
7. Oscillopsia is the sensation that viewed objects are moving or o Vertical nystagmus (refer to AVM/Neurology)
wavering back and forth, whilst the patient (especially the patient's o Cerebellar signs (refer to Neurology)
head) is moving.
These are purposefully very short guidelines. For more
References: http://cks.nice.org.uk/vertigo comprehensive information please see guidelines written by
Authors: Dr Victor Osei-Lah, Dr Peter West, Mr. N. Saunders, Dr Peter West. Click here.
Mr. S. Watts, Mr J Buckland, Dr D Whitehead
Others Involved: CWS ENT Task & Finish Group, WSHT LRMG
Date published: 05/13 Reviewed: 07/15 Review due: 07/17