- Perception of movement (rotational or otherwise) where no movement exists
- Don't assume that persistent vertigo that worsens with movement is benign; central vertigo may also worsen with movement
- Mismatch or asymmetric activity of visual, vestibular, and/or proprioceptive systems
- Evaluation should focus on determining whether the etiology is peripheral or central, with a secondary focus on diagnosis
- Peripheral: 8th CN, vestibular apparatus
- Central: Brainstem, cerebellum
- Many clinicians ask about presence of "room-spinning" sensation to distinguish lightheadedness vs vertigo, but this distinction may be of limited usefulness
- The ATTEST mnemonic can be helpful: Associated symptoms, Timing, Triggers, Exam Signs and Testing
- Vital for triaging benign vs dangerous conditions (see Clinical features)
- In any vertigo presentation, consider nonvertiginous causes such as presyncope, which may be medication-induced in a polypharmacy patient population
- Always take a full medication history
- Triggered episodic vestibular syndrome
- Spontaneous episodic vestibular syndrome
- Acute Vestibular Syndrome (AVS)
- Abrupt and persistent
- Can be exacerbated by movement but not triggered by it (i.e. symptoms persist at rest & exacerbated with movement)
- Benign: Vestibular Neuritis, Labyrinthitis
- Dangerous: Posterior Stroke
- Utilize HINTS Exam to differentiate
Central vs. Peripheral Causes of Vertigo
|Onset||Sudden||Sudden or slow|
|Severity||Intense spinning||Ill defined, less intense|
|Aggravated by position/movement||Yes||Variable|
|Nystagmus||Horizontal and unidirectional||Vertical and/or multidirectional|
|Fatigue of symptoms/signs||Yes||No|
|Hearing loss/tinnitus||May occur||Does not occur|
|Abnormal tympanic membrane||May occur||Does not occur|
|CNS symptoms/signs||Absent||Usually present|
- Cerebellar stroke
- Vertebrobasilar insufficiency
- Lateral Wallenberg syndrome
- Anterior inferior cerebellar artery syndrome
- Neoplastic: cerebellopontine angle tumors
- Basal ganglion diseases
- Vertebral Artery Dissection
- Multiple sclerosis
- Infections: neurosyphilis, tuberculosis
- Migraine (basilar)
- Glucose check
- Full neuro exam
- TM exam
- CTA or MRA (diagnostic study of choice) of the neck/brain if symptoms consistent with central cause
|CT non con||26%|
Proposed as method of distinguishing peripheral cause from cerebellar/brain stem CVA in the Emergency Department population.  Only to be used in patients with persistent dizziness, not those with resolved symptoms.
- HINTS exam should only be used in patient with acute persistent vertigo, nystagmus, and a normal neurological exam.
- HINTS exam, when done correctly, has high sensitivity and specificity in distinguishing peripheral vs central etiologies of vertigo
- Note that the original study was done by neuro-ophthalmologists in a differentiated patient base. This exam has not been studied in a large ED population yet
The 3 components of the HINTS exam include:
|HINTS Test||Reassuring Finding|
|Head Impulse Test||Abnormal (corrective saccade)|
|Test of Skew||No skew deviation|
- Always use correct terminology; "HINTS negative" does not convey a clear interpretation. State "HINTS central" or "HINTS peripheral" as suggested in literature
- If able, specify the exact exam finding as shown by chart above
Head Impulse Test
Test of vestibulo-ocular reflex function
- Have patient fix their eyes on your nose
- Move their head rapidly in the horizontal plane to the left and right
- When the head is turned towards the normal side, the vestibular ocular reflex remains intact and eyes continue to fixate on the visual target
- When the head is turned towards the affected side, the vestibular ocular reflex fails and the eyes make a visible corrective saccade to re-fixate on the visual target 
- Normally, a functional vestibular system will identify any movement of the head position and instantaneously correct eye movement accordingly so that the center of the vision remains on a target.
- This reflex fails in peripheral causes of vertigo affecting the vestibulocochlear nerve unilaterally; thus, failure of the reflex unilaterally is reassuring (since the cause is peripheral)
- Note that in central causes of vertigo, test may show normal reflex response OR failure of the reflex BILATERALLY
- Observation for nystagmus in primary, right, and left gaze
- No nystagmus (normal) or only horizontal unilateral nystagmus (fast direction only in one direction) is reassuring
- Any other type of nystagmus is abnormal, including vertical or bidirectional nystagmus
Test of Skew
- Have patient look at your nose with their eyes and then cover one eye
- Then rapidly uncover the eye and quickly look to see if the eye moves to re-align.
- Repeat with on each eye
- Skew deviation is a fairly specific predictor of brainstem involvement in patients with acute vestibular syndrome. The presence of skew may help identify stroke when a positive head impulse test falsely suggests a peripheral lesion.
- Skew is also known vertical dysconjugate gaze and is a sign of a central lesion
- A positive HINTS exam: 100% sensitive and 96% specific for the presence of a central lesion.
- The HINTS exam was more sensitive than general neurological signs: 100% versus 51%.
- The sensitivity of early MRI with DWI for lateral medullary or pontine stroke was lower than that of the HINTS examination (72% versus 100%, P=0.004) with comparable specificity (100% versus 96%, P=1.0).
- If any of the above 3 tests are consistent with CVA obtain full work-up (including MRI)
- Antihistamines: inhibit vestibular stimulation and vestibular-cerebellar pathways
- Scopolamine transdermal patch 0.5mg (behind ear) QID
- Metoclopramide 10-20 IV or PO TID
- Diazepam 2.5-10 mg q6h PRN
- use with caution in elderly population
- Epley maneuver (see BPPV)
- Most patients with peripheral vertigo can be discharged home
- All patients with central vertigo require urgent imaging and consultation while in the ED
- Prior to discharge, a trial of ambulation should be attempted:
- A peripheral vestibular lesion generally produces unidirectional postural instability with preserved walking
- An inferior cerebellar stroke often causes severe postural instability and falling
- Edlow JA, Newman-Toker D. Using the Physical Exam to Diagnose Patients with Acute Dizziness and Vertigo. J Emerg Med. 2016 Apr 50(4): 617-28.
- Kattah, J. et al. "HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging". Stroke. 2009. 40(11):3504–3510.
- Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007;369:293–8.
- Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493
- Kuo CH, Pang L, Chang R. Vertigo - part 1 - assessment in general practice. Aust Fam Physician. 2008;37(5):341-7