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 NICE CKS.
• 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 NICE NG127. Refer immediately for neuroimaging if a HINTS test shows indications of stroke (normal head impulse test, direction-changing nystagmus, or skew deviation) NICE NG127. 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 NICE CKS.
  • Very sudden onset of vertigo (within seconds) that is not provoked by positional change and is persistent NICE CKS.
  • Central neurological symptoms or signs (for example, new type of headache, especially occipital, gait disturbance, truncal ataxia, and vertical nystagmus) NICE CKS.
  • Acute deafness without other typical features of Meniere's disease NICE CKS.
  • 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 NICE NG127.
• 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 NICE CKS. 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 NICE NG127.
• Symptomatic Drug Treatment (while awaiting referral): While awaiting referral, consider offering symptomatic drug treatment for no longer than 1 week NICE CKS. To rapidly relieve severe nausea or vomiting, consider giving buccal prochlorperazine, or a deep intramuscular injection of prochlorperazine or cyclizine NICE CKS. To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine or cinnarizine, cyclizine, or promethazine teoclate (antihistamines) NICE CKS. Benzodiazepines are not recommended due to lack of evidence and potential for dependence NICE CKS.
• Deterioration: If the person's symptoms deteriorate, seek specialist advice NICE CKS.
• 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 NICE NG127.
  • 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 NICE NG127. Advise that dizziness will fluctuate and might increase during times of stress NICE NG127.
  • Refer adults with recurrent fixed-pattern dizziness associated with alteration of consciousness for an assessment for epilepsy NICE NG127.