Vertigo - overview and approach
Vertigo is the false sensation of movement, commonly described as “spinning.” It arises from dysfunction of the balance system anywhere between the peripheral vestibular apparatus (inner ear and vestibular nerve) and central structures (brainstem, cerebellum).
Differentiating peripheral from central causes is a core emergency task because immediate risks, investigations and management differ markedly. Recognise red flags that require urgent neurological / stroke pathway activation (NICE NG127).
This section summarises the clinical syndromes, focused history and examination (including bedside vestibular testing), indications for imaging and referral, ED management priorities, fitness‑to‑drive advice and high‑yield revision points for exams and practice.
Key guideline anchors
- NICE NG127: recognition and referral; Hallpike/Epley recommendations.
- NICE QS198: Hallpike quality statement.
- RCEM training expectations and local stroke pathway guidance.
- GOV.UK DVLA guidance for driving and dizziness.
Clinical syndromic classification (practical)
- Acute vestibular syndrome (AVS): continuous vertigo for days with nausea/vomiting, head‑motion intolerance and gait disturbance. Common causes: vestibular neuritis (peripheral), labyrinthitis, posterior circulation stroke (central).
- Episodic vestibular syndromes: discrete attacks separated by symptom‑free intervals. Examples: BPPV (very brief - seconds), Meniere’s disease (minutes-hours), vestibular migraine (minutes-days), posterior circulation TIA.
- Chronic disequilibrium: persistent unsteadiness rather than spinning (bilateral vestibular failure, cerebellar disease, peripheral neuropathy, medication effects).