Illusion of movement; classify as peripheral (vestibular) vs central (brainstem/cerebellum).
Etiology
- • Peripheral: BPPV, vestibular neuritis, Ménière
- • Central: stroke, MS, migraine
History taking
- • Onset, duration, triggers (head movement)
- • Hearing loss, tinnitus, neuro symptoms
Examination
- • Dix-Hallpike (BPPV), head impulse test
- • HINTS exam to differentiate central
- • Otoscopy, gait, cerebellar signs
Red flags
- • Central signs: vertical/direction-changing nystagmus, normal head impulse, skew deviation → MRI
Differential diagnosis
- • See differentials section per chief complaint
Recommended investigations
- • CBC, basic metabolic panel as indicated
- • Targeted disease-specific tests
Diagnosis
- • Clinical diagnosis supported by targeted investigations
Initial treatment / management
- • Treat underlying cause
- • Symptomatic relief
- • Patient education
Drug therapy
- • Epley manoeuvre for posterior canal BPPV
- • Prochlorperazine 5 mg TDS short course
- • Betahistine 16 mg TDS for Ménière
Follow-up advice
- • Review in 2–4 weeks or earlier if worsening
- • Monitor response to therapy and adverse effects
Patient counselling
- • Explain diagnosis and natural course in lay terms
- • Red-flag symptoms warranting urgent return
- • Adherence to medications and follow-up
Referral criteria
- • Refer if diagnostic uncertainty, complications, or failure of first-line therapy
Clinical pearls
- • HINTS-plus outperforms early MRI for posterior-circulation stroke
References
- • Harrison's Principles of Internal Medicine, 21e
- • NICE / WHO guidelines (current edition)
Educational outpatient guide — verify against local guidelines before clinical use.
