12/04/2026
Acute Vertigo:
Definitions
• Vertigo = false sensation of movement (spinning)
• Peripheral = inner ear cause
• Central = brainstem/cerebellum ( dangerous)
RED FLAG FIRST (Never Miss This)
Acute vertigo + ANY of the following → Think STROKE until proven otherwise
• Diplopia
• Dysarthria
• Ataxia
• Weakness
• New headache
• Risk factors (HTN, AF, DM)
Acute Vestibular Syndrome
1) Head Impulse Test • Abnormal → Peripheral
• Normal → Central
2) Nystagmus • Unidirectional → Peripheral
• Direction-changing → Central
3) Test of Skew • Skew deviation → Central
HINTS more sensitive than early CT for stroke
Common Causes
Peripheral
• BPPV (most common overall)
• Vestibular neuritis
• Meniere disease
Central (Dangerous)
• Cerebellar stroke
• Multiple sclerosis
• Brain tumor
Treatment Approach
1) BPPV (Most Common Cause)
Gold Standard (Exam + Practice)
Epley Maneuver (TOC)
• Immediate relief in most cases
• No drugs required
2) Vestibular Neuritis
• Prednisolone (early use improves recovery)
• Vestibular suppressants (short-term only)
3) Symptomatic Relief (Short Term Only )
• Prochlorperazine
• Meclizine
• Dimenhydrinate
Use only for 2–3 days (delays compensation if prolonged)
4) Meniere Disease
• Low salt diet
• Diuretics (e.g., thiazides)
• Avoid caffeine
Important Clinical Rule
Do NOT miss posterior circulation stroke
• Normal CT does NOT rule it out early
• MRI is better
• HINTS exam is key in acute setting
When to Investigate
• Red flags present
• Atypical features
• No improvement
• Recurrent unexplained episodes
Most Tested Associations
• BPPV → triggered by head movement
• Meniere → vertigo + tinnitus + hearing loss
• Vestibular neuritis → post-viral, no hearing loss
• Labyrinthitis → vertigo + hearing loss
