Which initial investigations should be considered for a patient presenting with acute vertigo?

For a patient presenting with acute vertigo, initial investigations should include a clinical assessment to identify any focal neurological deficits such as vertical or rotatory nystagmus, new-onset unsteadiness, or new-onset deafness. If such deficits are present, check for and treat hypoglycaemia in diabetic patients. If hypoglycaemia is not present or does not resolve symptoms, and benign paroxysmal positional vertigo (BPPV) or postural hypotension do not explain the presentation, urgent referral for neuroimaging to exclude posterior circulation stroke is required.

For sudden-onset acute vestibular syndrome (vertigo, nausea or vomiting, and gait unsteadiness), a HINTS (head-impulse–nystagmus–test-of-skew) test should be performed by a trained healthcare professional. A negative HINTS test makes stroke unlikely, whereas a positive test necessitates immediate neuroimaging referral. If a trained professional is not available, refer immediately according to local stroke pathways.

In cases of transient rotational vertigo on head movement, the Hallpike manoeuvre should be offered to check for BPPV if a trained professional is available. If BPPV is diagnosed, a canalith repositioning manoeuvre (e.g., Epley manoeuvre) should be offered if safe and feasible. If no trained professional is available or if cervical spine instability is present, refer according to local pathways.