Acute Dizziness and Vertigo in the Emergency Department

Document Overview

Document Title

Acute Dizziness and Vertigo in the Emergency Department

Authoring Society

Society for Academic Emergency Medicine

Document Publication Date

May 11, 2023

Page Last Reviewed/Updated

May 5, 2026

Document Type

Guideline

Country of Publication

United States

Full Text Freely Available

Yes

Full Text Guideline

onlinelibrary.wiley.com/doi/epdf/10.1111/acem.14728

Source Citation

Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med. 2023 May;30(5):442-486. doi: 10.1111/acem.14728. PMID: 37166022.

Supplemental Implementation Resources

• Video

Document Scope, Criteria, and Use Cases

Document Objectives

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

Scope

Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D014717 - Vertigo

D004244 - Dizziness

D014717 - Vertigo

D004244 - Dizziness

Keywords

Acute vestibular syndrome, BPPV, Spontaneous episodic vestibular syndrome, Triggered episodic vestibular syndrome, benign paroxysmal positional vertigo (BPPV), dizziness, emergency, vertigo

Target Patient Population

Patients seeking emergency care for acute vertigo or dizziness

Target Provider Population

Emergency physicians and other allied providers caring for patients in the emergency department

Inclusion Criteria

Male, Female, Adolescent, Older Adult

Health Care Settings

Emergency Care, Hospital

Intended Users

Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

Supplemental Methodology Resource

Data Supplement

Number of Source Documents

266

Literature Search End Date

Wednesday, September 29, 2021

Includes peer/external review process?

Yes

Includes public comment process?

No

Methodologist involvement?

Yes

Patient involvement?

Yes

Includes multi-disciplinary group?

Yes

Includes systematic review?

Yes

Grades quality of strength of evidence?

Yes

Grades quality of strength of recommendation?

Yes

Discloses funding source?

Yes

Discloses conflicts of interest?

Yes

Includes benefits/harms analysis with recommendations?

Yes