Acute Dizziness in the ED: Using the Timing-and-Triggers Approach

The Timing-and-Triggers Approach to the Patient With Acute Dizziness

Below is a free preview. Log in or subscribe for full access. Or, get a free sample article Emergency Department Management of Abnormal Uterine Bleeding in the Nonpregnant Patient:
Please provide a valid email address.

*NEW* Quick Search this issue!

Table of Contents
About This Issue

Although dizziness is common in the ED, there is incomplete understanding of the fundamentals of physical examination findings in dizzy patients. By using this new “timing-and-triggers” approach instead of the old “what do you mean, ‘dizzy?’” approach, you can more confidently make the correct diagnosis and ensure that patients with central causes of dizziness receive appropriate care quickly.

Define “vertigo,” “lightheadedness,” and “disequilibrium.” Why is the patient’s description of their symptom inherently unreliable?

How does the “timing-and-triggers” approach to dizziness more closely track with how other chief complaints are approached?

Neuritis versus stroke: how can you tell the difference?

When can a negative CT or MRI be false reassurance?

Why should you perform the “nystagmus” test portion of HINTS first?

What are the 5 questions you must answer “NO” to in order to rule out stroke?

When should you use the Epley maneuver? Semont? Lempert?

In a patient with triggered dizziness, what are the warning signs of a central cause?

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Selected Abbreviations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology, Relevant Anatomy, Physiology, and Pathophysiology
  7. Differential Diagnosis, Diagnostic Approach, and Misdiagnosis
    1. Symptom-Quality Approach
    2. Timing-and-Triggers Approach
    3. Misdiagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. Acute Vestibular Syndrome
      1. Head Impulse–Nystagmus–Test of Skew (HINTS) Testing
        • Test 1: Nystagmus Testing
        • Test 2: Skew Deviation Testing
        • Test 3: Head Impulse Testing
        • Test 4: Targeted Examination
        • Test 5: Gait Testing
    2. Spontaneous Episodic Vestibular Syndrome
    3. Triggered Episodic Vestibular Syndrome
  10. Diagnostic Studies
  11. Treatment
  12. Special Populations
  13. Controversies and Cutting Edge
  14. Disposition
  15. Summary
  16. Time- and Cost-Effective Strategies
  17. Key Points
  18. Risk Management Pitfalls for Dizziness in the Emergency Department
  19. Case Conclusions
  20. Clinical Pathways
    1. Clinical Pathway for the ATTEST Approach to Emergency Department Patients With Acute Dizziness
    2. Clinical Pathway for Diagnostic Evaluation of Patients With an Acute Vestibular Syndrome
  21. Tables and Figures
    1. Table 1. Timing-and-Trigger-Based Vestibulara Syndromes in Acute Dizziness and Their Corresponding Differential Diagnosis
    2. Table 2. Summary of Useful Physical Examination Findings in Symptomatic Patients With the Acute Vestibular Syndrome
    3. Table 3. Diagnostic Criteria for Vestibular Migraine
    4. Table 4. Benign Paroxysmal Positional Vertigo Physical Examination, Type of Nystagmus, and Therapeutic Maneuvers
    5. Table 5. Characteristics of Patients With Triggered Episodic Vestibular Syndrome That Suggest a Central Mimic (CPPV) Rather Than Typical BPPV
    6. Figure 1. Inner Ear Anatomy
    7. Figure 2. Vestibular Anatomy and Physiology
    8. Figure 3. Mechanisms of Benign Paroxysmal Positional Vertigo
    9. Figure 4. Cerebrovascular Anatomy of the Labyrinth
    10. Figure 5. Head Impulse Test
  22. Video Links
    1. Dix-Hallpike Maneuver
    2. Epley Maneuver
    3. Lempert (“barbecue”) maneuver
    4. Foster half-somersault maneuver for pc-BPPV
    5. Semont (liberatory) maneuver
    6. Gufoni maneuver
  23. Reference


Acute dizziness is a common presentation in the emergency department. Due to newer research, the diagnostic approach to dizziness has changed, now focusing on its timing and triggers of instead of the patient’s symptom quality (vertigo versus lightheadedness). Each timing-and-triggers category has its own differential diagnosis and diagnostic approach, which will aid emergency clinicians in distinguishing benign causes of dizziness from life-threatening causes. Brain imaging, even with magnetic resonance imaging, has important limitations in ruling out stroke presenting with dizziness. Benign paroxysmal positional vertigo can be treated with repositioning maneuvers at the bedside, offering cost-effective management options.

Case Presentations

The day shift signs out to you a 44-year-old previously healthy man. He is currently at CT. His dizziness started 6 hours previously and has been present ever since. He describes unsteadiness and “feeling like I am drunk,” and has vomited 3 times. He denies headache or neck pain, weakness, or numbness. His vital signs are normal. There is some left-beating horizontal nystagmus in primary gaze and in leftward gaze. The head impulse test is normal. The sign-out is that if his CT scan is normal, he can go home with meclizine and follow-up with his PCP in 2 days. That sounds reasonable, but you wonder if there is something else that needs to be considered...

The 70-year-old woman in room 3 complains of “lightheadedness” that has been going on for 5 days. It goes away at times, and gets worse when she gets out of bed. The dizziness has woken her from sleep several times. She has hypertension and high cholesterol. Her vital signs are normal. Sitting up in the stretcher, she is asymptomatic but feels apprehensive about moving her head. There is no nystagmus in primary gaze. You wonder if you should order a CT or if there is a better diagnostic test...

In room 7, there is a 58-year-old diabetic man whose triage chief complaint was syncope. On further questioning, he is reporting vertigo that is so severe it made him ease himself to the ground. There was no trauma, and it began abruptly 3 hours prior. Fingerstick glucose is 110 mg/dL. There is nystagmus on primary gaze that beats to the right, and when he looks to the right, the amplitude of the nystagmus increases. He is very nauseous and has vomited 3 times. A head impulse test is positive. Skew deviation is absent and he is mildly unsteady but can walk unassisted. You wonder if this could be stroke and whether the stroke team should be activated...

Selected Abbreviations

AICA Anterior inferior cerebellar artery
AVS Acute vestibular syndrome
BPPV Benign paroxysmal positional vertigo
ac-BPPV Anterior canal BPPV
hc-BPPV Horizontal canal BPPV
pc-BPPV Posterior canal BPPV
CPPV Central paroxysmal positional vertigo
EVS Episodic vestibular syndrome
s-EVS Spontaneous episodic vestibular syndrome
t-EVS Triggered episodic vestibular syndrome
HINTS Head impulse–nystagmus–test of skew
HIT Head impulse test
PICA Posterior inferior cerebellar artery
SCA Superior cerebellar artery
TIA Transient ischemic attack
VOR Vestibulo-ocular reflex


It is unusual to work a shift in the emergency department (ED) without seeing at least 1 patient with the complaint of dizziness. The challenge with these patients is due, in part, to the fact that the traditional diagnostic paradigm, which was created nearly 50 years ago, is deeply flawed and leads to confusion. Newer studies strongly suggest that a different diagnostic paradigm based on “timing and triggers” of the dizziness rather than the traditional “symptom quality” (or the “What do you mean, ‘dizzy’?”) approach is a better approach.

Compounding this problem is the fact that many physicians—and even some general neurologists—have an incomplete understanding of the basic physical examination findings that are useful in evaluating the dizzy patient. Nystagmus, in particular, is poorly understood by many clinicians, and the head impulse test (HIT) has only recently been introduced to emergency medicine practice. The goal of this article is to bridge this knowledge gap and to review the tools and techniques that are available to assist clinical decision-making in the dizzy patient.

Based on the current literature and clinical experience, this issue of Emergency Medicine Practice presents a new, algorithmic approach to the diagnosis of acute dizziness. Although this approach to the dizzy patient takes a few extra minutes up-front, it will save time and expense later. More importantly, confidently making a correct diagnosis in a timely fashion may improve patient outcomes, such as reducing falls due to dizziness and improving long-term vestibular function.1-3 In the case of transient ischemic attack (TIA), starting acute treatments reduces the outcome of stroke.4,5

Critical Appraisal of the Literature

A literature search was performed in PubMed and the Cochrane Database of Systematic Reviews. PubMed was searched using the terms vertigo, dizziness, disequilibrium, OR lightheadedness (limited to title or abstract), limited to the English language, up to November 1, 2018. Relevant Cochrane reviews in the ear, nose, and throat (ENT) and neurology sections were searched. This yielded 22,697 titles (PubMed) and 6 Cochrane reviews. No emergency medicine guidelines exist; however, the American Academy of Neurology6 and the American Academy of Otolaryngology-Head and Neck Surgery7 published practice guidelines on benign paroxysmal positional vertigo (BPPV) that have some overlap with emergency medicine practice.

Importantly, one study analyzed the strength of the evidence base in the literature on dizziness and found it to be weak.8 Of the literature that does exist, most studies were done in settings or by subspecialists that render them not relevant to ED practice. Therefore, I have used judgment to identify the very small proportion of articles relevant to the management of the acutely dizzy patient by emergency clinicians. Additional references from these articles were identified.

An important first step in critically appraising the literature on dizziness is to analyze the landmark article by Drachman and Hart published in 1972 in the journal Neurology.9 This article influenced subsequent medical literature and practice over the ensuing decades, and it forms the foundation of the “symptom-quality” approach to dizziness that is taught across specialty lines. The authors (a neurologist and an ENT specialist) established a “dizziness clinic” to which patients were referred. The patients underwent 4 half-days of evaluation, including history and detailed physical examination. A diagnosis was assigned by the lead author. Methodologic limitations of this study included:

Small number of patients: Only 125 patients were enrolled over a 2-year period, of whom 21 were rejected for inadequate data and another 9 for lack of a diagnosis. Only 95 patients completed the study.

  • Highly selected patient population: Recruited patients had to be fluent in English and available (and well enough) to return on 4 additional half-days for further testing in a clinic. These were not typical ED patients with dizziness, many of whom would have general medical conditions or be too sick (or die) to return for multiple repeat clinic visits.
  • Lack of independent verification of the diagnosis: The lead author assigned a diagnosis without any external verification. To some extent, circular reasoning was applied, in that a peripheral vestibular disorder was typically assigned to patients with rotatory nystagmus.
  • No long-term follow-up of patients: In addition to the lack of verification of the diagnosis, no follow-up was done, adding further ambiguity to the initial diagnostic accuracy.

Nonmethodologic limitations included:

  • Lack of any brain imaging: Neither computed tomography (CT) nor magnetic resonance imaging (MRI) was available in 1970-1972.
  • Some important diagnoses were not recognized at that time. Vestibular migraine was not an established diagnosis. Posterior circulation transient ischemic attack (TIA) presenting as isolated dizziness was not considered to occur.

The paradigm of “symptom quality” has never been prospectively validated, and the subjects of this study are not representative of ED patients with dizziness. Although the article was an important contribution in its time, it is fatally flawed. Newer evidence shows that its inherent logic is wrong.

Risk Management Pitfalls for Dizziness in the Emergency Department

1. “I thought that because the dizziness got worse with head movement, it had to be peripheral.”

This is a common misconception. Dizziness at rest in a patient with a cerebellar stroke or tumor often intensifies with head motion. It is crucial to distinguish dizziness that is triggered by movement (no dizziness at rest, but dizziness develops with movement) versus dizziness that is exacerbated by movement (dizziness is present at rest, but worsens with head movement).

3. “I ruled out a posterior circulation TIA because isolated dizziness is never due to ischemia; other brainstem findings will always be present.”

This is a misconception that stems from old expert opinion dating back to the mid-1970s. Newer studies make it clear that isolated dizziness is the most common transient symptom that precedes posterior circulation stroke and occurs in approximately 8% of these patients.

5. “The patient had a bad headache and said he had some transient double vision, but the Dix- Hallpike test was positive on both sides. I gave him meclizine for his BPPV.”

There are some symptoms that never occur with BPPV—including headache and double vision. One can never make a diagnosis of BPPV in a patient with severe headache or diplopia (even if transient). As well, the treatment for BPPV is a canalith repositioning maneuver such as the Epley maneuver, not meclizine.

Tables and Figures

Table 3. Diagnostic Criteria for Vestibular Migraine

Table 5. Characteristics of Patients With Triggered Episodic Vestibular Syndrome That Suggest a Central Mimic (CPPV) Rather Than Typical BPPV

Video Links

Dix-Hallpike Maneuver:

Epley Maneuver:

Lempert (“barbecue”) maneuver:

Foster half-somersault maneuver for pc-BPPV:

Semont (liberatory) maneuver:

Gufoni maneuver:


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

  1. Barin K, Dodson EE. Dizziness in the elderly. Otolaryngol Clin North Am. 2011;44(2):437-454. (Review article)
  2. Lawson J, Bamiou DE, Cohen HS, et al. Positional vertigo in a falls service. Age Ageing. 2008;37(5):585-589. (Cohort study; 59 elderly BPPV patients)
  3. Strupp M, Zingler VC, Arbusow V, et al. Methylprednisolone, valacyclovir, or the combination for vestibular neuritis. N Engl J Med. 2004;351(4):354-361. (Randomized controlled trial; 141 paitents with vestibular neuritis)
  4. Lavallee PC, Meseguer E, Abboud H, et al. A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects. Lancet Neurol. 2007;6(11):953-960. (Comparison trial; 1085 TIA patients for alternate immediate TIA clinic)
  5. Rothwell PM, Giles MF, Chandratheva A, et al. Effect of urgent treatment of transient ischaemic attack and minor stroke on early recurrent stroke (EXPRESS study): a prospective population-based sequential comparison. Lancet. 2007;370(9596):1432-1442. (Comparison trial; 1275 TIA patients, before & after a new immediate-access TIA clinic)
  6. Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70(22):2067-2074. (Guideline)
  7. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. (ENT practice guideline)
  8. Kerber KA, Fendrick AM. The evidence base for the evaluation and management of dizziness. J Eval Clin Pract. 2010;16(1):186-191. (Literature review)
  9. Drachman DA, Hart CW. An approach to the dizzy patient. Neurology. 1972;22(4):323-334. (Classic article that largely defined “symptom-quality” approach to dizziness)
  10. Edlow JA. Managing patients with acute episodic dizziness. Ann Emerg Med. 2018;72(5):602-610. (Review article)
  11. Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Arch Neurol. 1988;45(7):737-739. (Descriptive article of the development of the HIT)
  12. Newman-Toker DE, Hsieh YH, Camargo CA Jr, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83(7):765-775. (Cross-sectional analysis of a large national database)
  13. Edlow JA, Gurley KL, Newman-Toker DE. A new diagnostic approach to the adult patient with acute dizziness. J Emerg Med. 2018;54(4):469-483. (Review article)
  14. Edlow JA, Newman-Toker D. Using the physical examination to diagnose patients with acute dizziness and vertigo. J Emerg Med. 2016;50(4):617-628. (Review article)
  15. Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am. 2009;27(1):39-50. (Review article)
  16. Kerber KA, Newman-Toker DE. Misdiagnosing dizzy patients: common pitfalls in clinical practice. Neurol Clin. 2015;33(3):565-575. (Analysis and opinion article)
  17. Newman-Toker DE, Cannon LM, Stofferahn ME, et al. Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Mayo Clin Proc. 2007;82(11):1329-1340. (Cross-sectional study; 872 dizzy ED patients)
  18. Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke. 2006;37(10):2484-2487. (Population based study of stroke incidence in dizzy ED patients)
  19. Lawson J, Johnson I, Bamiou DE, et al. Benign paroxysmal positional vertigo: clinical characteristics of dizzy patients referred to a falls and syncope unit. QJM. 2005;98(5):357-364. (Retrospective study; 59 elderly BPPV patients)
  20. Newman-Toker DE, Dy FJ, Stanton VA, et al. How often is dizziness from primary cardiovascular disease true vertigo? A systematic review. J Gen Intern Med. 2008;23(12):2087-2094. (Systematic review)
  21. Edlow JA. Diagnosing dizziness: we are teaching the wrong paradigm! Acad Emerg Med. 2013;20(10):1064-1066. (Editorial)
  22. Edlow JA. A new approach to the diagnosis of acute dizziness in adult patients. Emerg Med Clin North Am. 2016;34(4):717-742. (Review article)
  23. Edlow JA. Diagnosing patients with acute-onset persistent dizziness. Ann Emerg Med. 2018;71(5):625-631. (Review article)
  24. Edlow JA, Newman-Toker DE. Medical and nonstroke neurologic causes of acute, continuous vestibular symptoms. Neurol Clin. 2015;33(3):699-716. (Review article)
  25. Pula JH, Newman-Toker DE, Kattah JC. Multiple sclerosis as a cause of the acute vestibular syndrome. J Neurol. 2013;260(6):1649-1654. (Prospective observational study; 170 patients with the AVS)
  26. Kattah JC. The spectrum of vestibular and ocular motor abnormalities in thiamine deficiency. Curr Neurol Neurosci Rep. 2017;17(5):40. (Targeted review article)
  27. Gulli G, Marquardt L, Rothwell PM, et al. Stroke risk after posterior circulation stroke/transient ischemic attack and its relationship to site of vertebrobasilar stenosis: pooled data analysis from prospective studies. Stroke. 2013;44(3):598-604. (Pooled analysis of prospective studies; 359 patients)
  28. Paul NL, Simoni M, Rothwell PM, et al. Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol. 2013;12(1):65-71. (Prospective population-based study; 1141 stroke patients)
  29. Hoshino T, Nagao T, Mizuno S, et al. Transient neurological attack before vertebrobasilar stroke. J Neurol Sci. 2013;325(1-2):39-42. (Single hospital-based cohort study; 214 patients with posterior circulation stroke)
  30. Lavallee PC, Sissani L, Labreuche J, et al. Clinical significance of isolated atypical transient symptoms in a cohort with transient ischemic attack. Stroke. 2017;48(6):1495-1500. (Cohort study; 1850 TIA patients)
  31. Plas GJ, Booij HA, Brouwers PJ, et al. Nonfocal symptoms in patients with transient ischemic attack or ischemic stroke: Occurrence, clinical determinants, and association with cardiac history. Cerebrovasc Dis. 2016;42(5-6):439-445. (Cohort study; 1265 TIA or minor stroke patients)
  32. Dunniway HM, Welling DB. Intracranial tumors mimicking benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1998;118(4):429-436. (Case series)
  33. Soto-Varela A, Rossi-Izquierdo M, Sanchez-Sellero I, et al. Revised criteria for suspicion of non-benign positional vertigo. QJM. 2013;106(4):317-321. (Review and opinion paper)
  34. Royl G, Ploner CJ, Leithner C. Dizziness in the emergency room: diagnoses and misdiagnoses. Eur Neurol. 2011;66(5):256-263. (Single German hospital cohort study; 475 ED dizzy patients who had neurologic consultation)
  35. Lee CC, Ho HC, Su YC, et al. Increased risk of vascular events in emergency room patients discharged home with diagnosis of dizziness or vertigo: a 3-year follow-up study. PLoS One. 2012;7(4):e35923. (3-year follow-up cohort study; 1118 dizzy ED patients)
  36. Atzema CL, Grewal K, Lu H, et al. Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol. 2015;79(1):32-41. (Retrospective population-based cohort; 41,794 discharged ED dizzy patients)
  37. Kerber KA, Meurer WJ, Brown DL, et al. Stroke risk stratification in acute dizziness presentations: a prospective imaging-based study. Neurology. 2015;85(21):1869-1878. (Prospective surveillance study; 272 discharged dizzy ED patients)
  38. Kim AS, Fullerton HJ, Johnston SC. Risk of vascular events in emergency department patients discharged home with diagnosis of dizziness or vertigo. Ann Emerg Med. 2011;57(1):34-41. (Retrospective review; 31,159 discharged dizzy ED patients)
  39. Calic Z, Cappelen-Smith C, Anderson CS, et al. Cerebellar infarction and factors associated with delayed presentation and misdiagnosis. Cerebrovasc Dis. 2016;42(5-6):476-484. (Prospective case series; 115 patients)
  40. Masuda Y, Tei H, Shimizu S, et al. Factors associated with the misdiagnosis of cerebellar infarction. J Stroke Cerebrovasc Dis. 2013;22(7):1125-1130. (Retrospective cohort study; 114 patients)
  41. Sangha N, Albright KC, Peng H, et al. Misdiagnosis of cerebellar infarctions. Can J Neurol Sci. 2014;41(5):568-571. (Retrospective cohort study; 47 patients)
  42. Arch AE, Weisman DC, Coca S, et al. Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke. 2016;47(3):668-673. (Retrospective cohort study; 485 patients)
  43. Nakajima M, Hirano T, Uchino M. Patients with acute stroke admitted on the second visit. J Stroke Cerebrovasc Dis. 2008;17(6):382-387. (Retrospective cohort study; 611 patients)
  44. Tarnutzer AA, Lee SH, Robinson KA, et al. ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology. 2017;88(15):1468-1477. (Systematic review/meta-analysis; 23 studies, 15,721 patients)
  45. Lee H, Sohn SI, Cho YW, et al. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology. 2006;67(7):1178-1183. (Retrospective cohort study; 240 patients)
  46. Dubosh NM, Edlow JA, Goto T, et al. Missed serious neurologic conditions in emergency department patients discharged with nonspecific diagnoses of headache or back pain. Ann Emerg Med. 2019;74(4):549-561. (Retrospective database analysis; 2.1 million ED discharges)
  47. Goldstein LB, Simel DL. Is this patient having a stroke? JAMA. 2005;293(19):2391-2402. (Systematic review)
  48. Kerber KA, Morgenstern LB, Meurer WJ, et al. Nystagmus assessments documented by emergency physicians in acute dizziness presentations: a target for decision support? Acad Emerg Med. 2011;18(6):619-626. (Chart review; 1091 patients)
  49. Grewal K, Austin PC, Kapral MK, et al. Missed strokes using computed tomography imaging in patients with vertigo: population-based cohort study. Stroke. 2015;46(1):108-113. (Retrospective cohort study; 41,794 patients)
  50. Oostema JA, Chassee T, Baer W, et al. Brief educational intervention improves emergency medical services stroke recognition. Stroke. 2019;50(5):1193-1200. (Results of 30-minute web-based training of EMS providers)
  51. Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504-3510. (Prospective study; 101 high-stroke-risk AVS patients)
  52. Saber Tehrani AS, Kattah JC, Mantokoudis G, et al. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology. 2014;83(2):169-173. (Ambispective study; 190 high-risk AVS patients)
  53. Chen L, Lee W, Chambers BR, et al. Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit. J Neurol. 2011;258(5):855-861. (Prospective study; 24 AVS patients)
  54. Vanni S, Nazerian P, Casati C, et al. Can emergency physicians accurately and reliably assess acute vertigo in the emergency department? Emerg Med Australas. 2015;27(2):126-131. (Convenience sample; 94 dizzy ED patients)
  55. Vanni S, Pecci R, Edlow JA, et al. Differential diagnosis of vertigo in the emergency department: a prospective validation study of the STANDING algorithm. Front Neurol. 2017;8:590. (Prospective validation study; 252 dizzy ED patients)
  56. Cnyrim CD, Newman-Toker D, Karch C, et al. Bedside differentiation of vestibular neuritis from central “vestibular pseudoneuritis”. J Neurol Neurosurg Psychiatry. 2008;79(4):458-460. (Retrospective analysis; 83 AVS patients)
  57. Carmona S, Martinez C, Zalazar G, et al. The diagnostic accuracy of truncal ataxia and HINTS as cardinal signs for acute vestibular syndrome. Front Neurol. 2016;7:125. (Retrospective cohort; 114 AVS patients)
  58. Neuhauser H, Lempert T. Vestibular migraine. Neurol Clin. 2009;27(2):379-391. (Review article)
  59. Furman JM, Marcus DA, Balaban CD. Vestibular migraine: clinical aspects and pathophysiology. Lancet Neurol. 2013;12(7):706-715. (Review article)
  60. Dieterich M, Obermann M, Celebisoy N. Vestibular migraine: the most frequent entity of episodic vertigo. J Neurol. 2016;263 Suppl 1:S82-S89. (Review article)
  61. Polensek SH, Tusa RJ. Nystagmus during attacks of vestibular migraine: an aid in diagnosis. Audiol Neurootol. 2010;15(4):241-246. (Retrospective study; 26 patients )
  62. Flossmann E, Rothwell PM. Prognosis of vertebrobasilar transient ischaemic attack and minor stroke. Brain. 2003;126(Pt 9):1940-1954. (Meta-analysis; 48 studies, 16,839 patients)
  63. Sajjadi H, Paparella MM. Meniere’s disease. Lancet. 2008;372(9636):406-414. (Review article)
  64. Bisdorff A. Vestibular symptoms and history taking. Handb Clin Neurol. 2016;137:83-90. (Review article)
  65. Ichijo H. Onset time of benign paroxysmal positional vertigo. Acta Otolaryngol. 2017;137(2):144-148. (Retrospective cohort study; 351 BPPV patients)
  66. Lindell E, Finizia C, Johansson M, et al. Asking about dizziness when turning in bed predicts examination findings for benign paroxysmal positional vertigo. J Vestib Res. 2018;28(3-4):339-347. (Prospective survey; 149 patients)
  67. Luscher M, Theilgaard S, Edholm B. Prevalence and characteristics of diagnostic groups amongst 1034 patients seen in ENT practices for dizziness. J Laryngol Otol. 2014;128(2):128-133. (Prospective observational study; 1034 patients )
  68. Balatsouras DG, Korres SG. Subjective benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2012;146(1):98-103. (Prospective cohort study; 63 patients)
  69. Huebner AC, Lytle SR, Doettl SM, et al. Treatment of objective and subjective benign paroxysmal positional vertigo. J Am Acad Audiol. 2013;24(7):600-606. (Retrospective cohort study; 63 patients)
  70. Tirelli G, D’Orlando E, Giacomarra V, et al. Benign positional vertigo without detectable nystagmus. Laryngoscope. 2001;111(6):1053-1056. (Prospective cohort study; 43 patients)
  71. De Stefano A, Kulamarva G, Citraro L, et al. Spontaneous nystagmus in benign paroxysmal positional vertigo. Am J Otolaryngol. 2010;32(3):185-189. (Retrospective cohort study; 412 patients)
  72. Imai T, Takeda N, Sato G, et al. Differential diagnosis of true and pseudo-bilateral benign positional nystagmus. Acta Otolaryngol. 2008;128(2):151-158. (Retrospective cohort study; 20 patients)
  73. Macdonald NK, Kaski D, Saman Y, et al. Central positional nystagmus: a systematic literature review. Front Neurol. 2017;8:141. (Systematic review)
  74. Ahsan SF, Syamal MN, Yaremchuk K, et al. The costs and utility of imaging in evaluating dizzy patients in the emergency room. Laryngoscope. 2013;123(9):2250-2253. (Chart review; 1681 patients)
  75. Hwang DY, Silva GS, Furie KL, et al. Comparative sensitivity of computed tomography vs. magnetic resonance imaging for detecting acute posterior fossa infarct. J Emerg Med. 2012;42(5):559-565. (Prospective cohort; 67 patients)
  76. Kabra R, Robbie H, Connor SE. Diagnostic yield and impact of MRI for acute ischaemic stroke in patients presenting with dizziness and vertigo. Clin Radiol. 2015;70(7):736-742. (Retrospective cohort study; 88 patients)
  77. Kerber KA, Schweigler L, West BT, et al. Value of computed tomography scans in ED dizziness visits: analysis from a nationally representative sample. Am J Emerg Med. 2010;28(9):1030-1036. (Retrospective analysis of a large national database)
  78. Lawhn-Heath C, Buckle C, Christoforidis G, et al. Utility of head CT in the evaluation of vertigo/dizziness in the emergency department. Emerg Radiol. 2013;20(1):45-49. (Retrospective cohort study; 448 patients)
  79. Wasay M, Dubey N, Bakshi R. Dizziness and yield of emergency head CT scan: is it cost effective? Emerg Med J. 2005;22(4):312. (Prospective cohort study; 344 patients)
  80. Kerber KA, Burke JF, Brown DL, et al. Does intracerebral haemorrhage mimic benign dizziness presentations? A population based study. Emerg Med J. 2011;29(1):43-46. (Analysis of national database; 595 patients)
  81. Edlow BL, Hurwitz S, Edlow JA. Diagnosis of DWI-negative acute ischemic stroke: a meta-analysis. Neurology. 2017;89(3):256-262. (Meta-analysis; 3236 patients)
  82. Choi JH, Kim HW, Choi KD, et al. Isolated vestibular syndrome in posterior circulation stroke: frequency and involved structures. Neurol Clin Pract. 2014;4(5):410-418. (Prospective cohort; 132 posterior stroke patients)
  83. Akoglu EU, Akoglu H, Cimilli Ozturk T, et al. Predictors of false negative diffusion-weighted MRI in clinically suspected central cause of vertigo. Am J Emerg Med. 2018;36(4):615-619. (Prospective cohort study; 137 ED AVS patients)
  84. Choi JH, Oh EH, Park MG, et al. Early MRI-negative posterior circulation stroke presenting as acute dizziness. J Neurol. 2018;265(12):2993-3000. (Prospective stroke registry; 850 patients with AVS)
  85. Filho JO, Mullen MT. Antithrombotic treatment of acute ischemic stroke and transient ischemic attack. UpToDate. October 2019. (Website)
  86. Chang AK, Schoeman G, Hill M. A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo. Acad Emerg Med. 2004;11(9):918-924. (Randomized controlled trial; 22 ED patients with BPPV)
  87. Kerber KA, Burke JF, Skolarus LE, et al. Use of BPPV processes in emergency department dizziness presentations: a population-based study. Otolaryngol Head Neck Surg. 2013;148(3):425-430. (Prospective population-based study; 3522 patients)
  88. Bashir K, Abid AR, Felaya A, et al. Continuing lack of the diagnosis of benign paroxysmal positional vertigo in a tertiary care emergency department. Emerg Med Australas. 2015;27(4):378-379. (Retrospective cohort study; 2727 patients)
  89. Polensek SH, Tusa R. Unnecessary diagnostic tests often obtained for benign paroxysmal positional vertigo. Med Sci Monit. 2009;15(7):MT89-MT94. (Retrospective cohort study; 193 patients)
  90. Newman-Toker DE, Saber Tehrani AS, Mantokoudis G, et al. Quantitative video-oculography to help diagnose stroke in acute vertigo and dizziness: toward an ECG for the eyes. Stroke. 2013;44(4):1158-1161. (Proof-of-concept study; 12 patients)
  91. Choi JH, Park MG, Choi SY, et al. Acute transient vestibular syndrome: prevalence of stroke and efficacy of bedside evaluation. Stroke. 2017;48(3):556-562. (Prospective cohort study; 83 patients)
  92. Edlow JA. Managing patients with transient ischemic attack. Ann Emerg Med. 2017;71(3):409-415. (Review article)
Publication Information

Jonathan A. Edlow, MD, FACEP

Peer Reviewed By

Petra Duran-Gehring, MD, RDMS, FACEP; Christopher Lewandowski, MD; Vasisht Srinivasan, MD

Publication Date

December 1, 2019

CME Expiration Date

December 1, 2022   

Pub Med ID: 31765116

Get Permission

Content you might be interested in
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.