When should I consider referring a patient with vertigo for specialist

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Consider referring a patient with vertigo for specialist assessment or imaging if any of the following are present:

Severe nausea and vomiting preventing oral fluid intake or symptomatic treatment, requiring hospital admission or urgent specialist referral .
Very sudden onset of vertigo (within seconds), persistent and not provoked by positional change .
Central neurological symptoms or signs such as new headache (especially occipital), gait disturbance, truncal ataxia, vertical nystagmus, cranial nerve weakness, sensory loss, or limb weakness ,.
New onset unilateral hearing loss with vertigo, as this may indicate stroke and requires urgent referral .
Isolated persistent vertigo lasting more than 24 hours with hyperacute onset, normal head impulse test, new headache, or other neurological signs ,.
Failure to respond to appropriate treatment for benign paroxysmal positional vertigo (BPPV) after two canalith repositioning procedures or presence of atypical symptoms/signs such as hearing loss, tinnitus, or middle ear infection signs .
Suspected migrainous vertigo requiring confirmation .
Sudden-onset acute vestibular syndrome with focal neurological deficit or if HINTS test indicates stroke, urgent neuroimaging is required .

While awaiting specialist assessment, consider short-term symptomatic drug treatment but do not delay referral ,.

When should I consider referring a patient with vertigo for specialist assessment or imaging?