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This is a clinician-written, evidence-based guide aligned to the MCC Examination Objectives. It is structured by clinical presentation — the way the MCCQE tests and the way patients actually present. Management reflects current Canadian guidelines (CMA, CFPC, CPS). Always cross-reference with institutional protocols and clinical judgment.
Key points
- Classify the symptom: vertigo (spinning), presyncope, disequilibrium/gait disorder or non-specific light-headedness.
- Central vertigo red flags: new headache/neck pain, focal neuro signs, severe truncal ataxia, direction-changing nystagmus, skew deviation, vascular risk and inability to walk.
- BPPV is brief positional vertigo triggered by rolling in bed or looking up; Dix-Hallpike confirms posterior canal BPPV and Epley treats it.
- Vestibular neuritis causes continuous vertigo for days after viral illness, with unidirectional nystagmus and no hearing loss.
- Do not rely on CT to exclude posterior circulation stroke; MRI and expert bedside examination are more useful when central features are present.
Approach to the Presentation
The MCCQE1 dizziness station tests whether you can translate a vague complaint into a syndrome. Ask about timing and triggers: triggered episodic vertigo suggests BPPV; spontaneous episodic vertigo suggests Ménière disease, vestibular migraine or TIA; acute vestibular syndrome suggests vestibular neuritis or posterior circulation stroke; chronic imbalance suggests neuropathy, cerebellar disease, Parkinsonism or medication effect.
Differential Diagnosis
| diagnosis | likelihood | key features | distinguishing test |
|---|---|---|---|
| Posterior circulation stroke / TIA | must-not-miss | Acute continuous vertigo with vascular risk, headache/neck pain, diplopia, dysarthria, dysphagia, limb ataxia, direction-changing nystagmus or inability to stand | MRI brain with DWI and vascular imaging; HINTS by trained clinician |
| Cerebellar haemorrhage | must-not-miss | Severe vertigo, headache, vomiting, ataxia, reduced consciousness, hypertension or anticoagulation | Urgent CT head; neurosurgical assessment |
| Vertebral artery dissection | must-not-miss | Neck pain/headache after minor trauma/manipulation, posterior circulation symptoms | CTA/MRA head and neck |
| BPPV | common | Brief recurrent positional vertigo lasting seconds, triggered by rolling in bed, looking up or bending | Dix-Hallpike with torsional upbeat nystagmus; Epley response |
| Vestibular neuritis | common | Continuous vertigo days, nausea/vomiting, unidirectional nystagmus, abnormal head impulse, no hearing loss | Clinical; HINTS pattern peripheral when performed correctly |
| Vestibular migraine | common | Vertigo with migraine history, photophobia, phonophobia or headache; episodes minutes-hours | Clinical after excluding central features |
| Orthostatic hypotension / presyncope | common | Light-headedness on standing, medications, dehydration, autonomic neuropathy | Orthostatic vitals |
| Medication/toxin-related dizziness | common | Sedatives, anticonvulsants, alcohol, aminoglycosides, antihypertensives; temporal association | Medication review and drug levels where relevant |
| Labyrinthitis | less common | Vestibular neuritis-like syndrome plus hearing loss/tinnitus | Audiometry; ENT assessment if severe |
| Ménière disease | less common | Recurrent vertigo 20 min-hours with fluctuating hearing loss, tinnitus and aural fullness | Audiometry |
Red Flags & Key History
Symptoms
Inability to walk unaided or severe truncal ataxia
Diplopia, dysarthria, dysphagia, unilateral weakness/numbness
New severe headache or neck pain
Acute hearing loss
Brief vertigo only with position change
Light-headedness when standing
Signs
Direction-changing or vertical nystagmus
Skew deviation
Focal cerebellar signs
Positive Dix-Hallpike with typical fatigable torsional nystagmus
Approach to Investigation
First-line
Orthostatic vitals and ECGFor presyncope/light-headedness or unclear dizziness.
Dix-HallpikeFor triggered positional vertigo; avoid if unstable cervical spine or vertebrobasilar concern.
Focused neurological exam including gaitGait inability is a major central red flag.
Second-line
MRI brain/vascular imagingWhen central features or posterior circulation stroke are suspected.
AudiometryFor hearing loss, tinnitus or suspected Ménière/labyrinthitis.
CT headUseful for haemorrhage, less sensitive for posterior ischemic stroke.
Specialist
Neurology/ENT referralCentral signs, sudden hearing loss, recurrent unexplained vertigo, or refractory vestibular symptoms.
Management Principles
Emergency Care BC acute vertigo guidance + CMAJ BPPV review1
Central vertigo suspected
- Activate stroke pathway and obtain urgent neurovascular imaging
- Do not reassure based on a normal early CT when posterior stroke remains likely
2
BPPV
- Treat posterior canal BPPV with Epley manoeuvre
- Avoid vestibular suppressants as long-term treatment; encourage return to activity
3
Vestibular neuritis
- Short course antiemetic/vestibular suppressant only for severe initial symptoms
- Vestibular rehabilitation and mobilization are key
4
Presyncope/non-vestibular
- Treat dehydration, medication effect, arrhythmia or anaemia according to cause
Complications & Pitfalls
- Missing posterior stroke: inability to stand, direction-changing nystagmus and focal signs are central until proven otherwise.
- Ordering CT as a rule-out test: CT is insensitive for early posterior fossa ischemia.
- Treating BPPV with chronic dimenhydrinate: repositioning manoeuvres are definitive.
- Not checking gait: gait often reveals central disease when cranial nerve testing is subtle.
MCCQE1 Exam Tips
- 1Timing-and-triggers beats asking 'what do you mean by dizzy?' repeatedly.
- 2BPPV: seconds, positional, Dix-Hallpike positive, Epley treatment.
- 3Vestibular neuritis: days of continuous vertigo, no hearing loss.
- 4Hearing loss shifts the differential to labyrinthitis, Ménière disease or AICA stroke.
- 5Vertical nystagmus, skew or direction-changing nystagmus are central signs.
- 6Normal CT does not exclude posterior circulation stroke.
Put your reading into practice
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