Step 1 of 8
Presentation & Vestibular Syndrome Category
Characterise the symptom and assign the syndrome — acute (continuous, days), episodic (recurrent attacks), or chronic (months to years)
The patient with a vestibular complaint presents with vertigo (a true spinning sensation), dizziness, disequilibrium, oscillopsia, motion sensitivity, visual dependence, falls or near-falls, gait instability, or chronic imbalance. The first analytic move is to assign the vestibular syndrome category, because the timing pattern reframes the whole differential.
The acute vestibular syndrome (AVS) is continuous symptoms lasting days — acute severe vertigo, nausea and vomiting, spontaneous nystagmus, gait instability and head-motion intolerance — and its causes span the benign (vestibular neuritis, labyrinthitis) and the dangerous (cerebellar and brainstem stroke). The episodic vestibular syndrome (EVS) is recurrent attacks separated by symptom-free intervals, lasting seconds to hours, caused by BPPV, Ménière disease, vestibular migraine, TIA or panic disorder. The chronic vestibular syndrome (CVS) is symptoms lasting months to years — bilateral vestibulopathy, persistent postural-perceptual dizziness, cerebellar degeneration, chronic unilateral hypofunction, or functional dizziness. This AVS/EVS/CVS triage is the spine of the algorithm, because the red-flag emphasis, the examination, and the likely diagnoses differ fundamentally between the three.
- Presentations — vertigo, dizziness, disequilibrium, oscillopsia, motion sensitivity, falls, gait instability, chronic imbalance
- Acute vestibular syndrome — continuous, days (vestibular neuritis, labyrinthitis, cerebellar/brainstem stroke)
- Episodic vestibular syndrome — recurrent attacks, seconds–hours (BPPV, Ménière, vestibular migraine, TIA, panic)
- Chronic vestibular syndrome — months–years (bilateral vestibulopathy, PPPD, cerebellar degeneration, functional dizziness)
★ High-yield pearls (chapter-wide)
- An acute vestibular syndrome with a central HINTS pattern is a posterior-circulation stroke until proven otherwise — a normal head-impulse test, direction-changing nystagmus, or skew deviation each point central, and in this setting HINTS outperforms early MRI.
- Classify the dizziness by its timing first — the acute (continuous, days), episodic (recurrent attacks) and chronic (months to years) vestibular syndromes each carry a distinct differential, and the temporal profile of attacks (seconds, minutes, hours) narrows it further.
- Vertigo with hearing loss mandates a comprehensive otologic evaluation — it points to Ménière disease, labyrinthitis, vestibular schwannoma or superior canal dehiscence rather than a benign vestibular cause.
- Vestibular migraine is now one of the commonest causes of recurrent vertigo, and it is a clinical diagnosis — episodic vertigo with migraine features and motion sensitivity, often without hearing loss.
- Treat BPPV with the canal-specific repositioning manoeuvre and always follow it with a balance assessment, particularly in the older adult in whom residual imbalance and fall risk persist after the vertigo resolves.
- Persistent postural-perceptual dizziness is a positive diagnosis — chronic dizziness for more than three months, worse upright, with motion and in busy visual environments — and it needs multidisciplinary treatment: vestibular rehabilitation, cognitive behavioural therapy and an SSRI/SNRI.
- Bilateral vestibulopathy causes oscillopsia and imbalance that is worse in the dark, and it is rehabilitated by sensory substitution — using vision and proprioception — rather than by VOR adaptation, which requires residual function.
- Early mobilisation and vestibular rehabilitation improve central compensation after vestibular neuritis — vestibular suppressants are for the first few days only and then impede recovery.
- Falls-risk assessment and prevention should be built into every vestibular-rehabilitation programme, especially for the patient over 65 with previous falls, bilateral loss, neuropathy or visual impairment.
- Vestibular rehabilitation must be individualised — by diagnosis, residual vestibular function, age, migraine status, cognition, psychological comorbidity and fall risk — not prescribed as a single generic exercise set.
Evidence base
2 sources- HIGH
Steenerson KK · Continuum (Minneap Minn) · 2021ReviewPMID 34351112
Review of the acute vestibular syndrome, framing its presentation and the peripheral-versus-central distinction.
- HIGH
Edlow JA, Carpenter C, Akhter M · Acad Emerg Med · 2023Practice guidelinePMID 37166022
Emergency-department guidelines for the reasonable and appropriate care of the acute dizzy patient, including the syndrome-based approach.
Decision tree
The dizziness is classified by syndrome and screened for central red flags — in the acute vestibular syndrome, HINTS separates a peripheral cause from a posterior-circulation stroke. The temporal profile and examination then route the patient to one of eleven diagnosis-keyed pathways.