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) from presyncope/light-headedness (a feeling of being about to faint, which points towards cardiovascular or orthostatic causes), and from 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?”. The more reliable approach is to categorise by timing and triggers, which maps cleanly onto the likely diagnosis and the single most useful bedside test. The two skills that matter in primary care are to treat the common, benign causes within the consultation and 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 | HINTS (only if spontaneous nystagmus is present) |
| Triggered, brief, positional – seconds, on head movement / rolling over in bed | 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, or 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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