Guideline sources The following summarized guidelines for the evaluation and management of dizziness and vertigo are prepared by our editorial team based on guidelines from the Society for Academic Emergency Medicine (SAEM 2023), the European Society for Vascular Surgery (ESVS 2023), the American Physical Therapy Association (APTA 2022), the United States Department of Defense (DoD/VA 2021; 2016), the American College of Radiology (ACR 2018), the Living Concussion Guidelines (LCG 2017), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2017), and the American Academy of Neurology (AAN 2017). 1 2 3 4 5 6 7 8 9 Calculator Calculator Calculat HINTS examination for stroke in ICVD criteria for M ni re's disea Recogn Guidelines 1. Diagnostic investigations Oculomotor assessment: https://web.pathway.md/diseases/recfF9yX6FwsgXs5p 1/6 6/29/23, 10:20 PM Dizziness and vertigo Pathway Obtain routine three-component head impulse-nystagmus-test of skew examination by clinicians trained in its use to distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses in adult patients with acute vestibular syndrome with nystagmus presenting to the emergency department. A Consider eliciting a detailed history and performing a physical examination with emphasis on cranial nerves, including visual fields, eye movements, limb coordination, and gait assessment, to help distinguish between central (TIA) and peripheral (vestibular migraine, M ni re's disease) diagnoses in adult patients with spontaneous episodic vestibular syndrome presenting to the emergency department. C Hearing assessment: consider obtaining hearing assessment at the bedside by finger rub to identify new unilateral hearing loss as an additional criterion to aid in the identification of stroke, even if head impulse-nystagmus-test of skew examination result suggests a peripheral vestibular diagnosis in adult patients with acute vestibular syndrome with nystagmus. C Gait assessment: Consider eliciting a detailed history and performing a physical examination with emphasis on cranial nerves, including visual fields, eye movements, limb coordination, and gait assessment, to distinguish between central (TIA) and peripheral (vestibular migraine, M ni re's disease) diagnoses in adult patients with spontaneous episodic vestibular syndrome presenting to the emergency department. C Consider obtaining a severity assessment of gait unsteadiness to help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses in adult patients with acute vestibular syndrome without nystagmus presenting to the emergency department. C Dix-Hallpike maneuver: As per SAEM 2023 guidelines, perform the Dix-Hallpike maneuver for the diagnosis of posterior canal-benign paroxysmal positional vertigo in adult patients with transient-episodic vestibular syndrome presenting to the emergency department. B As per AAO-HNSF 2017 guidelines, perform the Dix-Hallpike maneuver (by bringing the patient from an upright to supine position with the head turned 45 degrees to one side and the neck extended 20 degrees with the affected ear down) to elicit provoked vertigo associated with torsional, upbeating nystagmus for the diagnosis of posterior semicircular canal benign paroxysmal positional vertigo. Repeat the maneuver with the opposite ear down if the initial maneuver is negative. B Supine roll test: obtain a supine roll test to assess for lateral semicircular canal benign paroxysmal positional vertigo in patients with a history compatible with benign paroxysmal positional vertigo and horizontal or no nystagmus during the Dix-Hallpike maneuver. B Vestibular function testing: As per AAN 2017 guidelines, avoid obtaining cervical vestibular evoked myogenic potential testing for the diagnosis of benign paroxysmal positional vertigo. D As per AAO-HNSF 2017 guidelines, do not obtain routine vestibular testing in patients meeting diagnostic criteria for benign paroxysmal positional vertigo without additional vestibular signs and/or symptoms warranting testing. D https://web.pathway.md/diseases/recfF9yX6FwsgXs5p 2/6 6/29/23, 10:20 PM Dizziness and vertigo Pathway Diagnostic imaging (acute vestibular syndrome): do not obtain routine non-contrast CT of the brain or CT angiography to help distinguish between central (stroke) and peripheral (inner ear, usually vestibular neuritis) diagnoses in adult patients with acute vestibular syndrome (with or without nystagmus) presenting to the emergency department. D Show 2 more Diagnostic imaging, episodic vestibular syndrome: As per ESVS 2023 guidelines, obtain cervical vascular imaging to identify disruption of blood flow during head turning for the diagnosis of vertebrobasilar ischemia (attributed to nipping of the vertebral arteries on head movement) in patients with vertigo or dizziness on head turning. B As per SAEM 2023 guidelines, do not obtain routine CT to distinguish between central (TIA) and peripheral (vestibular migraine, M ni re's disease) diagnoses in adult patients with spontaneous episodic vestibular syndrome presenting to the emergency department. D Show 2 more As per ACR 2018 guidelines, obtain temporal bone CT or head and internal auditory canal MRI in patients with episodic vertigo with or without associated hearing loss or aural fullness (peripheral vertigo). B Diagnostic imaging (persistent vertigo): obtain head and internal auditory canal MRI in patients with persistent vertigo with or without neurological symptoms (central vertigo). B Diagnostic imaging, BPPV: As per SAEM 2023 guidelines, avoid obtaining routine MRI or MRA in adult patients with transient-episodic vestibular syndrome presenting to the emergency department and diagnosed with typical posterior canal-benign paroxysmal positional vertigo by a positive Dix- Hallpike test with the characteristic nystagmus. D As per AAO-HNSF 2017 guidelines, do not obtain radiographic imaging in patients meeting diagnostic criteria for benign paroxysmal positional vertigo without additional signs and/or symptoms warranting imaging. D 2. Medical management Management of benign paroxysmal positional vertigo: As per SAEM 2023 guidelines, perform the Epley canalith repositioning maneuver at the time of diagnosis in adult patients with posterior canal-benign paroxysmal positional vertigo diagnosed by a positive Dix-Hallpike test. B As per AAO-HNSF 2017 guidelines, perform a canalith repositioning procedure for the treatment of patients with posterior canal benign paroxysmal positional vertigo. Do not advise postprocedural postural restrictions after the canalith repositioning procedure. B Show 6 more Management of vestibular neuritis: consider ensuring shared decision-making with patients to weigh the risks and benefits of short-term corticosteroid treatment in adult patients with a clinical diagnosis of vestibular neuritis presenting within 3 days of symptom onset. C https://web.pathway.md/diseases/recfF9yX6FwsgXs5p 3/6 6/29/23, 10:20 PM Dizziness and vertigo Pathway 3. Specific circumstances Patients with post-concussion vestibular dysfunction, acute mTBI: As per LCG 2017 guidelines, perform the Dix-Hallpike maneuver for assessment of patients with symptoms of benign positional vertigo once the cervical spine has been cleared. E Show 3 more As per DoD/VA 2016 guidelines: Consider offering a short-term trial of specific vestibular, visual, and proprioceptive therapeutic exercises to assess the individual patient's responsiveness to treatment in patients with a history of mild TBI presenting with functional impairments due to dizziness, disequilibrium, and spatial disorientation symptoms. Avoid offering a prolonged course of therapy in the absence of patient improvement. C Refer patients to occupational therapy, physical therapy, or other vestibular-trained care providers as appropriate. B Patients with post-concussion vestibular dysfunction (post-acute mTBI): consider offering a trial of specific vestibular rehabilitation and proprioceptive therapeutic exercise in patients with persistent symptoms of dizziness and imbalance attributed to mild TBI. C 4. Follow-up and surveillance Vestibular rehabilitation: As per APTA 2022 guidelines, offer vestibular physical therapy in patients with acute, subacute, or chronic unilateral vestibular hypofunction. A Show 9 more As per AAO-HNSF 2017 guidelines, consider offering vestibular rehabilitation, either self- administered or administered by a clinician, in the treatment of patients with benign paroxysmal positional vertigo. C 5. Quality improvement Health professional training: ensure that emergency department clinicians receive training in bedside physical examination techniques for acute vestibular syndrome (head impulse- nystagmus-test of skew) and diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (Dix-Hallpike test and Epley maneuver). B Clinical findings Symptoms Past medical history Dizziness Benign paroxysmal positional vertigo Fainting Brain tumor Gait disturbance Concussion Hearing loss Labyrinthitis Lightheadedness https://web.pathway.md/diseases/recfF9yX6FwsgXs5p 4/6 6/29/23, 10:20 PM Dizziness and vertigo Pathway Loss of balance Migraine Pre-syncope Multiple sclerosis Vertigo M ni re's disease Orthostatic hypotension Past events Otosclerosis Persistent postural-perceptual dizziness Falls Stroke Neurological exam Superior canal dehiscence syndrome Nystagmus Dix-Hallpike test TBI head impulse-nystagmus-test of skew TIA Vertebral artery disease Vestibular neuronitis Vital signs Orthostatic hypotension References 1. No authors listed. Living Concussion Guidelines: Guideline for Concussion & Prolonged Symptoms for Adults 18 years of Age or Older: 2017 April Update. ConcussionsOntario. 2017 Apr. Open 2. Bhattacharyya N, Gubbels SP, Schwartz SR et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo Update). Otolaryngol Head Neck Surg. 2017 Mar;156 3_suppl):S1 S47. Open 3. Jonathan A Edlow, Christopher Carpenter, Murtaza Akhter et al. Guidelines for reasonable and appropriate care in the emergency department 3 GRACE 3 Acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023 May;30 5 442 486. Open 4. Courtney D Hall, Susan J Herdman, Susan L Whitney et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association. J Neurol Phys Ther. 2022 Apr 1;46 2 118 177. Open 5. Expert Panel on Neurologic Imaging:, Aseem Sharma, Claudia F E Kirsch et al. ACR Appropriateness Criteria Hearing Loss and/or Vertigo. J Am Coll Radiol. 2018 Nov;15 11S S321 S331. Open 6. Terry D Fife, James G Colebatch, Kevin A Kerber et al. Practice guideline: Cervical and ocular vestibular evoked myogenic potential testing: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2017 Nov 28;89 22 2288 2296. Open 7. Ross Naylor, Barbara Rantner, Stefano Ancetti et al. Editor's Choice European Society for Vascular Surgery ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg. 2023 Jan;65 1 7 111. Open 8. Department of Defense/Veterans Affairs. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT AND REHABILITATION OF POST ACUTE MILD TRAUMATIC BRAIN INJURY. VA/DoD. 2021 Jun. Open 9. Department of Defense/Veterans Affairs. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF CONCUSSION MILD TRAUMATIC BRAIN INJURY. VA/DoD. 2016 Feb. Open https://web.pathway.md/diseases/recfF9yX6FwsgXs5p 5/6 6/29/23, 10:20 PM Dizziness and vertigo Pathway https://web.pathway.md/diseases/recfF9yX6FwsgXs5p 6/6