How should I approach the management of a patient with recurrent episodes of dizziness without a clear diagnosis?

When managing a patient experiencing recurrent episodes of dizziness with no clear diagnosis, the approach should involve a thorough assessment, consideration of urgent referral criteria, and appropriate specialist referral, with symptomatic treatment as an interim measure.

• Initial Assessment: Assess the person's symptoms, medical history, and clinical findings ¹.
• Urgent Referral Criteria: Immediately refer adults with sudden-onset acute vestibular syndrome if benign paroxysmal positional vertigo (BPPV) or postural hypotension do not account for the presentation, especially if a healthcare professional trained in the HINTS test is unavailable ⁴. Refer immediately for neuroimaging if a HINTS test shows indications of stroke (normal head impulse test, direction-changing nystagmus, or skew deviation) ⁴. Consider hospital admission or urgent referral to an appropriate specialist if the person has:
  • Severe nausea and vomiting and is unable to tolerate oral fluids or symptomatic drug treatment ¹.
  • Very sudden onset of vertigo (within seconds) that is not provoked by positional change and is persistent ¹.
  • Central neurological symptoms or signs (for example, new type of headache, especially occipital, gait disturbance, truncal ataxia, and vertical nystagmus) ¹.
  • Acute deafness without other typical features of Meniere's disease ¹.
  • Sudden-onset dizziness with a focal neurological deficit such as vertical or rotatory nystagmus, new-onset unsteadiness, or new-onset deafness, after checking for and treating hypoglycaemia if applicable ⁴.
• Referral for Undetermined Cause: For all other people with vertigo of undetermined cause, refer to a balance specialist (ear, nose, and throat specialist, audiovestibular physician, neurologist, or care of the elderly physician with a special interest), with the urgency depending on the person's symptoms, clinical findings, and clinical judgement ¹. If transient rotational vertigo on head movement is present and BPPV is suspected but a healthcare professional trained in the Hallpike manoeuvre or canalith repositioning manoeuvre (e.g., Epley) is not available, refer in accordance with local pathways ⁴.
• Symptomatic Drug Treatment (while awaiting referral): While awaiting referral, consider offering symptomatic drug treatment for no longer than 1 week ¹. To rapidly relieve severe nausea or vomiting, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine or cyclizine ¹. To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine or cinnarizine, cyclizine, or promethazine teoclate (antihistamines) ¹. Benzodiazepines are not recommended due to lack of evidence and potential for dependence ¹.
• Deterioration: If the person's symptoms deteriorate, seek specialist advice ¹.
• Specific Considerations:
  • Be alert to the possibility of vestibular migraine in adults who have episodes of dizziness lasting between 5 minutes and 72 hours and a history of recurrent headache ⁴.
  • For adults diagnosed with a functional neurological disorder by a specialist, be aware that recurrent dizziness might be part of the disorder and may not require re-referral if there are no new neurological signs ⁴. Advise that dizziness will fluctuate and might increase during times of stress ⁴.
  • Refer adults with recurrent fixed-pattern dizziness associated with alteration of consciousness for an assessment for epilepsy ⁴.