One-liner#

Adult/geriatric outpatient approach to dizziness: classify the symptom (vertigo vs presyncope vs imbalance), identify stroke and other emergencies, and treat high-yield outpatient causes (BPPV, orthostasis, medication effects).

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• New focal neuro deficits (weakness, facial droop, speech difficulty) or severe new headache
• Severe gait ataxia/inability to walk, or persistent vomiting/dehydration
• New hearing loss with neuro symptoms, or severe neck pain/headache (vascular concern)
• Syncope, chest pain, palpitations, or hemodynamic instability

Key history#

• Symptom type:
  • Vertigo: “room spinning”
  • Presyncope: “lightheaded,” “about to faint”
  • Imbalance: “unsteady,” “walking like drunk”
• Timing and triggers: seconds with position change (BPPV) vs constant for days (neuritis) vs episodic (Ménière/migraine)
• Provoked by head movement vs standing vs exertion
• Associated symptoms: hearing changes/tinnitus, headache/migraine symptoms, neuro deficits, nausea/vomiting
• Meds/substances: antihypertensives, sedatives, anticholinergics, alcohol (especially in older adults)
• Hydration, recent illness, falls/head strike
• Clarify “how long” precisely:
  • Seconds (BPPV) vs minutes–hours (migraine/Ménière) vs days (neuritis) vs chronic imbalance (neuropathy/vision/meds)

Focused exam#

• Vitals including orthostatics when presyncope suspected
  • Orthostatic criteria: ≥20 mmHg systolic drop OR ≥10 mmHg diastolic drop within 3 minutes of standing (or 60° head-up tilt)
• Cardiac exam and rhythm check; consider ECG threshold low in older adults
• Neuro screen and gait assessment (if safe)
• Eye exam: nystagmus characterization; EOM
• BPPV testing: Dix-Hallpike (posterior canal) when appropriate; if negative but history classic, consider horizontal canal variant (supine roll test)
• Hearing screen if reported change (Weber/Rinne or whisper test)
• Caveat on HINTS: reserve for acute vestibular syndrome (continuous vertigo + nystagmus + gait unsteadiness) when you are trained; if uncertainty or red flags exist, use ED pathway rather than relying on bedside tests.

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

• For classic BPPV with benign exam: no routine imaging/labs.
• For presyncope or older adults with unclear dizziness: consider ECG and orthostatics.
• Labs only if suggested by history/exam (e.g., anemia, dehydration, metabolic derangement).
• If red flags or abnormal neuro exam: ED pathway and imaging per protocol.
• If orthostasis suspected: focus on medication review, volume status, and orthostatic vitals rather than broad imaging.

Initial management#

• Safety first: fall-risk counseling; avoid driving/heights until stable.
• Treat the likely category (positional vs orthostatic vs vestibular vs central) rather than “dizziness” generically.
• Avoid prolonged vestibular suppressants; they can delay compensation (use short-term only if needed, per protocol).
• If falls are part of the presentation, consider also using Gait instability / falls and the MSK injury pathway Falls: MSK injury evaluation.

Management by diagnosis#

BPPV#

Education:

• Benign positional vertigo is common; symptoms are triggered by specific head positions
• Caused by displaced crystals in the inner ear; not dangerous but can cause falls
• Usually resolves with repositioning maneuvers; may recur

Treatment:

• Perform Dix-Hallpike to confirm the side; treat with Epley (posterior canal) in clinic when possible
• Home plan: repeat repositioning as instructed (Brandt-Daroff exercises if Epley not feasible)
• Refer to vestibular PT if recurrent/persistent or if diagnosis is unclear

Avoid prolonged vestibular suppressants—they impair central compensation and prolong recovery.

Follow-up: 1–2 weeks if persistent; sooner if new neuro symptoms.

Orthostatic hypotension#

Education:

• Often medication/dehydration related; stand up slowly
• Common in elderly; can cause falls and syncope
• May take weeks to improve with interventions

Treatment:

• Non-pharmacologic first: hydration (2–3 L/day if tolerated), salt intake (if no HF), slow position changes, compression stockings (thigh-high preferred)
• Review/adjust contributing medications:

Pharmacologic treatment (if non-pharmacologic fails and no supine HTN):

Follow-up: 1–2 weeks (or sooner if falls).

Vestibular neuritis#

Education:

• Usually improves over days to weeks; imbalance can linger for weeks
• Caused by viral inflammation of the vestibular nerve; not dangerous
• Early movement and exercises speed recovery

Treatment:

• Short-term antiemetic/vestibular suppressants only if needed for severe nausea (max 3 days):

• Early vestibular rehab/exercises (Cawthorne-Cooksey); hydration and sleep
• Reassess if new hearing loss, recurrent episodes, or new neuro symptoms

Follow-up: 1–2 weeks if function-limiting; vestibular PT referral if not improving.

Vestibular migraine#

Education:

• Vertigo can be a migraine manifestation even without severe headache
• Episodes typically last minutes to hours; may have motion sensitivity between attacks
• Same triggers as typical migraine (sleep, stress, diet)

Treatment:

• Acute: treat as migraine (see Headache)
• Preventive (if frequent episodes):

Follow-up: 4–6 weeks to assess preventive efficacy.

Posterior circulation stroke/TIA concern#

• Education: sudden severe imbalance can be stroke even without arm/leg weakness.
• Treatment: ED now for urgent neuro evaluation and imaging per protocol.
• Follow-up: ED pathway.

Ménière’s disease (suspected)#

Education:

• Episodic vertigo (20 min to hours) with fluctuating hearing loss, tinnitus, and ear fullness
• Chronic condition with unpredictable attacks; hearing loss may become permanent
• Dietary salt restriction and avoiding triggers may reduce attack frequency

Treatment:

• Acute attacks: meclizine 25 mg PRN (short-term); ondansetron for nausea
• Preventive: low-sodium diet (<2 g/day); avoid caffeine, alcohol, tobacco
• Diuretics (hydrochlorothiazide 25 mg daily or triamterene/HCTZ) sometimes used but evidence limited

Referral: ENT/otology for audiometry, confirmation, and long-term management. Urgent if sudden hearing loss.

Follow-up: 2–4 weeks; coordinate with ENT.

Follow-up#

• Reassess in 1–2 weeks for persistent symptoms, falls, or unclear diagnosis.
• Reassess in 4–6 weeks for vestibular migraine plan effectiveness.
• Escalate urgently for new weakness/numbness, severe gait instability, chest pain/syncope, or severe new headache.
• If not improving after 2–4 weeks (or recurrent episodes), escalate (vestibular PT, med review optimization, reconsider cardiac/central causes, and imaging/referral thresholds).

When to refer:

• ENT/Otology: hearing loss with vertigo (Ménière’s, labyrinthitis), recurrent BPPV, suspected perilymph fistula
• Neurology: suspected vestibular migraine not responding to treatment, concern for central cause, atypical presentations
• Vestibular PT: BPPV not responding to office maneuvers, persistent imbalance after vestibular neuritis, chronic dizziness

Patient instructions#

• Avoid driving/heights until dizziness is improving and you feel steady.
• Stand up slowly and stay well hydrated; review any new meds with your clinician.
• If you were diagnosed with positional vertigo, do the home maneuver as instructed.
• Seek urgent care now for new weakness/numbness, trouble speaking, severe imbalance (can’t walk), chest pain, fainting, or a severe new headache.

Smartphrase snippets#

BPPV, treated in office: Positional vertigo consistent with BPPV: brief spinning triggered by position change, positive Dix-Hallpike [R/L]. Epley maneuver performed in office. No red flags, neuro exam normal. Home exercises reviewed. Return if symptoms persist >2 weeks or new neuro symptoms develop.

Orthostatic hypotension: Dizziness on standing consistent with orthostatic hypotension. Orthostatic vitals positive (supine [X/X], standing [X/X]). Reviewed contributing medications. Plan: increase fluids, slow position changes, [medication adjustment]. Recheck in 1–2 weeks. Return precautions for syncope or falls reviewed.

Dizziness, reassurance after workup: Dizziness evaluated. No red flags for stroke (no focal deficits, no severe ataxia, no acute onset with vascular risk). Neuro exam normal. Most consistent with [BPPV/orthostasis/vestibular migraine]. Plan: [treatment]. Follow up in [X] weeks. Return immediately for new weakness, numbness, severe imbalance, or syncope.

Related pages#

Complaint pages#

• Syncope — if presyncope vs true syncope evaluation
• Headache — vestibular migraine overlap
• Falls (geriatric) — if dizziness causing falls in elderly
• Gait instability/Falls — if imbalance is prominent feature
• Hearing loss — if hearing loss with vertigo (Ménière’s, labyrinthitis)

Problem pages#

• Orthostatic hypotension — detailed orthostasis management
• BPPV — comprehensive benign positional vertigo management
• Peripheral Neuropathy — if imbalance from sensory loss