GPAtlas🧭 When to suspect (vertigo vs light-headedness)
The first decision is what the patient actually means by “dizzy”. Separate:
• True vertigo: a false sensation of movement – spinning, tilting, rocking.
• Presyncope/light-headedness: a feeling of being about to faint, which points towards cardiovascular or orthostatic causes.
• Disequilibrium: unsteadiness on the feet without illusory movement.
Vertigo localises the problem to the vestibular system – the inner ear or its central connections.
Once vertigo is established, do not rely on the old question “what does the dizziness feel like?”.
• It is more reliable to categorise by timing and triggers, which points to the likely diagnosis and the most useful bedside test.
The two skills that matter in primary care:
• To treat the common, benign causes within the consultation.
• To never miss a central cause – above all a posterior circulation stroke presenting as acute vestibular syndrome (sudden, continuous vertigo lasting more than 24 hours).
| Pattern (timing & trigger) | Think of | Key bedside test |
|---|---|---|
| Acute vestibular syndrome – sudden, continuous vertigo lasting days | Vestibular neuritis vs posterior circulation stroke | Head impulse, nystagmus, test of skew (HINTS) (only if spontaneous nystagmus is present) |
| Triggered, brief, positional – seconds, on head movement or rolling over in bed | • Benign paroxysmal positional vertigo (BPPV) (the commonest cause overall) • Orthostatic hypotension |
Dix–Hallpike (and lying/standing BP) |
| Spontaneous, episodic – minutes to hours, recurrent | Vestibular migraine (commonest recurrent cause), Ménière’s disease, TIA | History ± audiometry if aural symptoms |
Raise concern for a central cause in anyone with:
• Vascular risk factors (age, smoking, hypertension, diabetes, atrial fibrillation).
• A new headache or neck pain.
• Any focal neurology.
• Severe truncal ataxia.
Vestibular migraine is “central” in origin but benign; the dangerous central cause to exclude is stroke.
Source: NICE NG127 · BMJ Practice (Acute vertigo, 2019)
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