Vertigo Update

Dizziness can be difficult to assess in the ED given the vast range of etiologies and varying ways patients interpret their symptoms. Additionally, not all patients with emergency conditions will present with obvious focal deficits. A clinical decision making rule (HINTS) can help to more rapidly identify stroke patients to initiate acute therapies faster. The HINTS rule outperforms ABCD2  for stroke diagnosis in the ED when performed by qualified practitioners in patients with Acute Vestibular Syndrome. 

Typically, patients with peripheral vertigo appear to have an acute change and may be very ill appearing, with nausea and vomiting and severe vertigo symptoms. Those with central vertigo typically have a more insidious onset, constant symptoms, and typically less severe symptoms. 

Common Causes

• Basilary/Posterior Stroke
• BPPV
• Vestribular Neuritis
• Meniere's Disease

Signs of a Central Cause

Symptoms of a central vertigo may be difficult to identify. Typically, there are some of the "5 D's"

• Dizziness
• Dysarthria
• Diplopia
• Dysphagia
• Dysmetria
• Ataxia

HINTS Exam

LINK TO 8 MINUTE HOW TO VIDEO

Indications of a Central Cause: 

• Head-Impulse Test without a defect/loss of fixation
• ​Nystagmus: Any vertical , torsional, or direction-changing nystagmus
• Positive vertical test of skew ​

From: HINTS Outperforms ABCD2 Score to screen for stroke

Pharmacologic Management

• BPPV: Treated with benzodiazapines or meclizine
• Vestibular Neuritis: Consider starting steroids, methylprednisolone 100mg daily and tapered slowly.

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