• Dizziness, 3–4% of ED visits, costing US >$4 billion/yr, difficult symptom to diagnose, often misdiagnosed
  • Patients use various words to describe their experience including:
    • Vertigo (the illusory sense of movement)
    • Weakness, fainting
    • Lightheadedness
    • Unsteadiness
  • Key point: The word that patients use (e.g., vertigo vs. dizziness vs. lightheadedness) is not diagnostically important. It is the timing and triggers that drive the evaluation (see below)
  • To best find the cause, rather than focusing on the descriptor the patient uses, take a standard history focusing on trying to see if the patient has some toxic-metabolic-infectious cause (e.g., a GI bleed or a systemic infection or a dysrhythmia), which is the case in 50% of ED patients with dizziness
  • If not obvious cause, use timing and triggers to place the patient into one of 3 categories:
    • Acute vestibular syndrome (AVS) – acute onset of continuous dizziness
    • Triggered episodic vestibular syndrome (t-EVS) – brief episodes of dizziness triggered, usually by movements of the head or body
    • Spontaneous episodic vestibular syndrome (s-EVS) – longer episodes of dizziness not triggered by anything


  • Toxic-metabolic-infectious causes:
    • Toxins and many medications
    • Electrolyte disturbances and dehydration
    • Systemic infections
    • Dysrhythmias
  • AVS:
    • Most common cause – vestibular neuritis and labyrinthitis
    • Posterior circulation stroke
    • Multiple sclerosis
    • Wernicke
  • Triggered-EVS:
    • BPPV
    • Orthostatic hypotension
    • Rarely central positional paroxysmal vertigo (CPPV)
  • Spontaneous-EVS:
    • Vestibular migraine
    • TIA (posterior circulation)
    • Ménière disease
    • Panic attacks
    • Rarely, intermittent low flow states (e.g., dysrhythmias or PE)

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