Intended for healthcare professionals

Practice 10-Minute Consultation

Acute vertigo

BMJ 2019; 366 doi: (Published 12 September 2019) Cite this as: BMJ 2019;366:l5215
  1. Diego Kaski, consultant neurologist1,
  2. Kiran Agarwal, general practitioner2,
  3. Louisa Murdin, consultant audiovestibular physician3
  1. 1National Hospital for Neurology and Neurosurgery, London, UK
  2. 2Eastwick Park Medical Practice, Surrey, UK
  3. 3Ear, Nose and Throat Department, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, London, UK
  1. Correspondence to L Murdin Louisa.Murdin{at}

What you need to know

  • Benign paroxysmal positional vertigo (BPPV) can be quickly diagnosed within a consultation with the Dix-Hallpike manoeuvre. BPPV should be treated with a repositioning manoeuvre, not medication

  • Postural restrictions after repositioning manoeuvres are no longer recommended

  • Refer urgently as a suspected stroke if patients have associated neurological symptoms and signs or prolonged continuous vertigo and vascular risk factors

A 56 year old woman visits her general practitioner. She says she feels like her head is spinning. She has associated nausea but no vomiting. She is able to walk unaided but feels very unsteady.

Assessing a patient with vertigo is a diagnostic challenge for the clinician, particularly in the acute setting where symptoms can be extremely debilitating.1 However, the most common cause of vertigo, benign paroxysmal positional vertigo (BPPV), can be diagnosed and often successfully treated within a consultation. This article describes how to briefly assess someone with acute vertigo, to identify the likely diagnosis and guide initial management.

What you should cover

Taking a history

If the patient describes dizziness, ask about the quality of the symptom: vertigo is a sensation of false movement of the world, or an internal sensation of movement, tilt, or spatial disorientation.2 Clinical features of the causes of acute vertigo are described in the infographic (fig 1).

Fig 1

Diagnosing common causes of vertigo in primary care

The severity and overwhelming nature of vertigo and anxiety that it provokes often make it hard to establish a clear picture of the patient’s experience of vertigo. People with acute vertigo tend to experience anxiety owing to the physiological link between vestibular inputs and the autonomic nervous system and limbic structures, which create a fight or flight response. High state anxiety levels are a negative predictor of long term clinical recovery following acute vertigo.1

Vertigo can be of peripheral …

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