Giddiness: clinical evaluation, differential diagnosis, and management

• Vertigo: illusion of spinning or motion
• Presyncope: feeling about to faint, often worse upright
• Disequilibrium: imbalance while walking or standing
• Nonspecific light-headedness: floating, vague dizziness, often multifactorial

1. Immediate triage: identify emergencies

• New focal neurologic deficit: facial asymmetry, limb weakness/numbness, dysarthria, diplopia, dysphagia
• New inability to stand or walk unaided, marked truncal ataxia
• Continuous severe vertigo with central-pattern eye findings
• Sudden severe headache, neck pain, altered consciousness, seizure
• Syncope, chest pain, palpitations, dyspnea, or known significant heart disease
• Persistent vomiting with dehydration
• New unilateral hearing loss with acute vestibular symptoms
• High vascular risk with possible posterior-circulation TIA or stroke

2. Focused history

Characterize the episode

1. Onset: sudden or gradual? First episode or recurrent?
2. Timing: seconds, minutes, hours, or continuous for days?
3. Triggers:
   • Rolling in bed, looking up, bending: BPPV
   • Standing up: orthostatic hypotension, volume depletion, medication effect
   • Exertion: arrhythmia, structural cardiac disease
   • Visual motion, stress, busy environments: vestibular migraine or persistent postural-perceptual dizziness
4. Associated symptoms:
   • Hearing loss, tinnitus, ear fullness: Ménière disease or other peripheral ear disease
   • Nausea/vomiting: common in acute vestibular disorders, but also possible in stroke
   • Headache, photophobia, phonophobia: vestibular migraine
   • Palpitation or blackout: arrhythmia or reflex syncope
   • Neurologic symptoms: TIA/stroke, demyelination, migraine aura

Review risk factors and medications

• Vascular risk: age, hypertension, diabetes, smoking, dyslipidemia, atrial fibrillation, prior stroke/TIA
• Dehydration, blood loss, fever, poor intake
• Alcohol or recreational drugs
• New or changed drugs: antihypertensives, diuretics, alpha-blockers, beta-blockers, nitrates, sedatives, anticholinergics, antihistamines, anticonvulsants, antidepressants, hypoglycemics, ototoxic drugs

3. Differential diagnosis

A. Triggered episodic dizziness, lasting seconds to minutes

B. Spontaneous episodic symptoms, minutes to hours

C. Acute continuous vestibular syndrome, lasting days

D. Chronic dizziness or imbalance

• Bilateral vestibular hypofunction
• Peripheral neuropathy or posterior-column dysfunction
• Parkinsonism or other gait disorder
• Visual impairment
• Drug effects
• Anxiety/panic disorder
• Persistent postural-perceptual dizziness
• Anemia, thyroid disease, metabolic disturbances where clinically suggested

4. Examination

Basic assessment

• Vital signs, temperature, oxygen saturation
• Orthostatic BP and pulse: measure supine or seated and after standing. Orthostatic hypotension is a sustained fall of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing. AAFP guidance
• Hydration status
• Cardiovascular examination and pulse regularity
• Full neurologic examination: cranial nerves, speech, power, sensation, cerebellar function, gait, Romberg
• Eye examination: spontaneous and gaze-evoked nystagmus, ocular alignment, visual fields
• Ear examination and bedside hearing assessment

Targeted bedside tests

• Dix-Hallpike: only for brief, position-triggered vertigo suspicious for posterior-canal BPPV.
• Supine roll test: if horizontal-canal BPPV suspected.
• HINTS examination: head impulse, nystagmus, test of skew. Use only in a patient with acute continuous vestibular syndrome with spontaneous nystagmus, and only by a clinician trained in its performance and interpretation. A central or equivocal result warrants stroke evaluation and MRI/MRA where appropriate. GRACE-3 recommendations

5. Investigations: selective, not routine

Usually appropriate when indicated

• Capillary blood glucose
• ECG for presyncope, syncope, palpitations, cardiac history, or older/high-risk patients
• CBC if anemia, bleeding, infection, or systemic illness is plausible
• Electrolytes, renal function, and pregnancy test when clinically relevant
• Audiometry for persistent/unilateral auditory symptoms or suspected Ménière disease
• Holter/event monitor if intermittent arrhythmia suspected

Neuroimaging

• Urgent MRI brain with diffusion imaging, with vascular imaging when indicated, for suspected posterior-circulation stroke/TIA or central findings.
• CT head is often insensitive for posterior-fossa ischemia and should not be used merely to distinguish peripheral from central vertigo.
• Routine imaging is not needed for classic BPPV with a positive positional test and no neurologic red flags. GRACE-3 guideline

6. Management by cause

General measures

• Treat dehydration and correct hypoglycemia if present.
• Review and reduce offending medicines where safe.
• Falls advice: avoid driving, heights, machinery, or walking alone while symptomatic.
• Refer/admit if an unsafe gait, recurrent syncope, central signs, persistent vomiting, or diagnostic uncertainty with high risk.

BPPV

• Perform a canalith repositioning procedure, usually the Epley maneuver, for posterior-canal BPPV.
• Vestibular suppressants such as meclizine are generally not the main treatment and may delay compensation if used repeatedly.
• Refer for vestibular physiotherapy/ENT if atypical, recurrent, or treatment-resistant. The Epley maneuver has strong guideline support. GRACE-3

Vestibular neuritis

• Short-term antiemetic or vestibular suppressant only for severe acute nausea/vertigo, typically limited to 1-3 days.
• Start early mobilization and vestibular rehabilitation.
• Steroids may be discussed within 3 days of onset, but the guideline rates evidence for meaningful clinical benefit as very low. GRACE-3
• Ensure stroke has been reasonably excluded before diagnosing neuritis.

Ménière disease

• ENT assessment and audiometry.
• Education on triggers; individualized dietary and preventive management.
• Manage acute attacks symptomatically; specialist-directed preventive treatment may be needed.

Vestibular migraine

• Manage acute migraine symptoms where suitable.
• Regular sleep, hydration, meals, exercise, trigger management.
• Consider preventive migraine therapy for frequent or disabling attacks, individualized to comorbidities.

Orthostatic hypotension

• Correct fluids, blood loss, and precipitating medication effects.
• Rise slowly, maintain fluids and salt intake when appropriate, compression garments in selected patients.
• Assess for autonomic disease if persistent.

Cardiac or systemic cause

• Arrhythmia, anemia, infection, electrolyte disturbance, hypoglycemia, and drug toxicity require cause-specific treatment, often with urgent referral depending on severity.

Practical one-line approach