dizziness and vertigo in adults - NICE guidance - suspected neurological conditions - recognition and referral

Last edited 05/2019

Dizziness and vertigo in adults

Summary points from NICE guidance relating to dizziness and vertigo in adults are:

Sudden-onset dizziness with a focal neurological deficit

• for adults with sudden-onset dizziness and a focal neurological deficit such as vertical or rotatory nystagmus, new-onset unsteadiness or new-onset deafness:
  
  
  • if the person has diabetes, check for and treat hypoglycaemia
    
    
  • if the person does not have diabetes, or treating hypoglycaemia does not resolve the symptoms, and benign paroxysmal positional vertigo or postural hypotension do not account for the presentation, refer immediately to exclude posterior circulation stroke

 

Sudden-onset acute vestibular syndrome

• for adults with sudden-onset acute vestibular syndrome (vertigo, nausea or vomiting and gait unsteadiness), a HINTS (head-impulse-nystagmus-test-ofskew) test should be performed if a healthcare professional with training and experience in the use of this test is available
  
  
• for adults with sudden-onset acute vestibular syndrome who have had a HINTS test:
  
  
  • be aware that a negative HINTS test makes a diagnosis of stroke very unlikely
    
    
  • refer immediately for neuroimaging if the HINTS test shows indications of stroke (a normal head impulse test, direction-changing nystagmus or skew deviation)
    
    
• refer immediately adults with sudden-onset acute vestibular syndrome in whom benign paroxysmal positional vertigo or postural hypotension do not account for the presentation, in line with local stroke pathways, if a healthcare professional with training and experience in the use of the HINTS test is not available

 

Sudden-onset dizziness with no imbalance or focal neurological deficit

• be aware that dizziness in adults with no imbalance or other focal neurological deficit is unlikely to indicate a serious neurological condition

Vertigo on head movement

For adults with transient rotational vertigo on head movement:

• offer the Hallpike manoeuvre to check for benign paroxysmal positional vertigo (BPPV) if a healthcare professional trained in its use is available
  • if there is no healthcare professional trained in the Hallpike manoeuvre available, refer in accordance with local pathways
    
    
• If BPPV is diagnosed, offer a canalith repositioning manoeuvre (such as the Epley manoeuvre) if a healthcare professional trained in its use is available and if the person does not have unstable cervical spine disease. If there is no healthcare professional trained in a canalith repositioning manoeuvre available, or the person has unstable cervical spine disease, refer in accordance with local pathways
  
  
• be aware that BPPV is common after a head injury or labyrinthitis

Vestibular migraine

• be alert to the possibility of vestibular migraine (migraine-associated vertigo) in adults who have episodes of dizziness that last between 5 minutes and 72 hours and a history of recurrent headache.

Recurrent dizziness as part of a functional neurological disorder

• be aware that, for adults who have been diagnosed with a functional neurological disorder by a specialist, recurrent dizziness might be part of the disorder and the person might not need re-referral if there are no new neurological signs. New symptoms or signs in adults who have been diagnosed with a functional neurological disorder by a specialist should be assessed
  
  
• advise adults with recurrent dizziness and a diagnosed functional neurological disorder that their dizziness will fluctuate and might increase during times of stress

Dizziness with altered consciousness

• refer adults with recurrent fixed-pattern dizziness associated with alteration of consciousness to have an assessment for epilepsy

Reference:

• NICE (May 2019). Suspected neurological conditions: recognition and referral