Dizziness & vertigo: documentation that holds up

The dizzy patient is a stroke trap dressed as a benign complaint. The modern, defensible approach abandons "what kind of dizzy?" for timing and triggers, screens every patient for central features, and — done right — favors the bedside exam over a CT that can't see the problem.

01What's at stake

The can't-miss is posterior-circulation stroke, and a non-contrast CT essentially can't exclude it. Strokes happen in the young (vertebral dissection), and a "normal-looking" patient can be harboring one — baseline stroke risk in acute continuous vertigo is ~10%, rising toward ~80% when any neurologic sign is present. The GRACE-3 guideline reframes the whole workup around the bedside exam.

02Classify by timing & triggers (not "type")

• Acute vestibular syndrome — continuous dizziness for days, symptomatic at rest, with nystagmus. Benign: vestibular neuritis. Can't-miss: posterior stroke.
• Spontaneous episodic — recurrent spells, minutes–hours, no trigger. Benign: vestibular migraine. Can't-miss: TIA.
• Triggered episodic — brief, seconds, positional. Benign: BPPV / orthostatic.

03Central red flags — screen everyone

• The dangerous Ds: diplopia, dysarthria, dysmetria, dysphonia, dysphagia. → central
• New headache (hemorrhage) or new neck pain (vertebral dissection). → central
• Inability to walk unaided / severe truncal ataxia. → central
• Vertical or torsional nystagmus at rest, or direction-changing nystagmus. → central
• New unilateral hearing loss (AICA territory). → central

04The exams

• HINTS (only in acute vestibular syndrome with nystagmus, by a trained examiner): Head-Impulse, Nystagmus, Test-of-Skew. Reassuring/peripheral = an abnormal head impulse with catch-up saccade, unidirectional horizontal nystagmus, and no skew. A normal head impulse, direction-changing/vertical nystagmus, or any skew is central. A benign HINTS by a skilled examiner is more sensitive than early MRI.
• HINTS-plus adds a bedside hearing check.
• Don't apply HINTS without nystagmus — it gives false "central" results (BPPV, migraine, anemia, hyponatremia).
• Dix-Hallpike for triggered/positional vertigo — upbeat-torsional nystagmus toward the down ear is benign posterior-canal BPPV (treat with Epley, not meclizine).
• Gait in everyone — inability to walk unaided is a red flag.

05Imaging (GRACE-3)

• Recommend against non-contrast CT/CTA to distinguish central from peripheral — it can't.
• In acute vestibular syndrome with a central or equivocal HINTS → stroke-protocol MRI.
• Typical BPPV diagnosed by Dix-Hallpike → no imaging.
• Episodic with TIA concern → consider CTA/MRA of the posterior circulation.

06What to document

07Where charts fail

• Working up dizziness with a CT and discharging on meclizine.
• Applying HINTS to a patient without nystagmus (false "central" or false reassurance).
• Forgetting that a normal head impulse is the worrisome one in true acute vestibular syndrome.
• Not documenting the central red flags asked-and-denied, or the gait exam.
• Mistaking benign Dix-Hallpike nystagmus for a central sign — or missing down-beating nystagmus that is central.

08Sources

• Edlow JA, Carpenter CR, Akhter M, et al. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): acute dizziness and vertigo. Acad Emerg Med. 2023;30(5):442-486.
• Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke. 2009;40(11):3504-3510.
• Tarnutzer AA, Berkowitz AL, Robinson KA, et al. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011;183(9):E571-E592.
• Newman-Toker DE, Edlow JA. TiTrATE: a novel approach to diagnosing acute dizziness and vertigo. Neurol Clin. 2015;33(3):577-599.

© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from the GRACE-3 guideline and primary literature. Synthetic examples. Not medical advice — apply local protocol and judgment.