Not Another Patient with Dizziness! - Evidence Based Pearls for Your Practice

Dizziness accounts for 4-5% of all emergency department (ED) chief complaints and 26% of ED patients endorse dizziness in their review of systems.  Although most presentations for dizziness are benign, nearly 200,000 strokes present with dizziness each year in the United States (Edlow et al. 2008).   Misdiagnosis of vertebrobasilar strokes is common, as symptoms may be minimal and patients often change how they characterize their symptoms.  Dr. Siket covers a systematic and evidence based approach to guide your workup of this all too common patient.  

Here are the key takeaways from his lecture:

  • Use the ATTEST history to characterize the patient's dizziness.
  • Categorize your patient's "dizziness" as Acute Vestibular Syndrome (AVS), Chronic Vestibular Syndrome (CVS), Episodic Vestibular Syndrome (EVS), or Triggered Vestibular Syndrome (TVS) to guide your workup.
  • The presence and type of nystagmus can help determine if the patient's dizziness is from a central or peripheral cause.
  • Use the HINTS exam to help diagnose the cause of your patient's Acute Vestibular Syndrome.
  • Trust your physical exam more than MRI in the first 48 hours.
PE for dizziness.jpg
  • Selectively use provocative testing (i.e. Dix Hallpike test).
  • Avoid “boxing in” your patients to a "type of dizziness" when taking a history.
  • Do not presume the patient has Benign Paroxysmal Positional Vertigo just because their symptoms worsen with head movement.



Maine Medical Center Undifferentiated dizziness guideline

Maine Medical Center Undifferentiated dizziness guideline

Additional FOAMed Resources

1.  FOAM cast episode 51 - Vertigo

2.  The David Newman-Toker Ophthalmology collection of videos

3.  EM Docs - A simplified approach to the patient with dizziness

4.  EMCRIT podcast 33 - Diagnosis of Posterior Stroke



1.       Edlow JA et al. Lancet Neurol 2008

2.       Edlow JA & Selim MH Lancet Neurol 2011

3.       Edlow JA.  Acad Emerg Med 2013

4.       Newman-Toker DE, et al. Mayo Clin Proc 2007

5.       Atzema CL, et al. Ann Neurol 2016

6.       Kattah JC et al. Stroke 2009

7.       Newman-Toker DE, et al. Neurology 2008

8.       Newman-Toker DE et al Acad Emerg Med 2013

9.       Halmagyi GM Curthoys IS. Arch Neurol 1988

10.    Henry GL, et al. Neurologic Emergencies 3rd Ed. 2010 Ch. 14

11.    Chen K, et al. BMC Emerg Med 2016

12.    Grewal K, et al. Stroke 2015

13.    Edlow JA and Newman-Toker D. J Emerg Med 2016

14.    Bhattacharyya N, et al. Otolaryngol Head Neck Surg 2008

15.    Kerber KA. Emerg Med Clin N Am. 2008

16.    Vanni S et al. Acta Otorhinolaryngol Ital 2014

17.    Vanni S et al. Emerg Med Australasia 2015


Written by Matthew S. Siket, MD, MS
Assistant Professor of Emergency Medicine
Alpert Medical School of Brown University
Providence, RI

Edited and posted by Jeffrey A. Holmes, MD