This guidance is aimed at primary care clinicians. It outlines the primary care treatment and referral pathways for the common causes of dizziness in adults (18 years of age and above) in NHS South West London. It is also available as a visual summary flow chart. In addition, the dizziness training webinar delivered across SWL is a useful resource.
The following are outside the scope of this guideline:
- Invasive diagnostic procedures. Patients requiring these procedures should be referred to secondary care via the most appropriate pathway as determined in the guidance.
- Primary care management of dizziness in migraine. Refer to the SWL headache referral and management guidance for recommendations on the prevention of migraine.
- Dizziness caused by complex neurological conditions, complex cardiovascular causes, and psychiatric causes of dizziness.
Recommendations
Assessment of patient
- Take a relevant patient history and review the patient’s medication list.
- Enquire if the patient has a history of vertigo; room or head spinning, unsteadiness, light headiness, non-specific, single or recurrent episodes, the duration.
Examination of patient
- Take postural blood pressure then conduct a focused neurological examination:
- HINTS plus (Head impulse test, nystagmus type, test of skew, plus hearing)
- Cranial nerves, weakness, sensory deficit, ataxia, cerebellar signs.
- Gait assessment
- Positional manoeuver (Diagnostic – Modified Hallpike). NICE guidance supports the referral if the GP does not have the necessary skills to preform these manoeuvers.
Investigations
- Check blood glucose, postural blood pressure
Diagnosis and Treatment
Benign positional paroxysmal vertigo (BPPV):
- Brief seconds to minutes of positionally triggered vertigo with or without associated nausea or unsteadiness.
- Upbeat and torsional nystagmus on positional testing.
- Treat using repositioning manoeuver Semont/Epley.
- Refer to specialist vestibular physiotherapy service if not improved.
Vestibular neuritis
- Prolonged vertigo with or without nausea, vomiting, unsteadiness.
- Head thrust positive, unidirectional nystagmus.
- Treat using antiemetics (prochlorperazine for one week). If not improved in two to three weeks, refer to local vestibular rehabilitation team.
Labyrinthitis
- Prolonged vertigo with or without nausea, vomiting, unsteadiness.
- Head thrust positive, unidirectional nystagmus, hearing loss.
- Treat using antiemetics (prochlorperazine for one week).
- Refer to local clinic as per local guidelines (ENT/AVM/Neurovestibular).
Vestibular migraine
- Headaches with migrainous features (nausea, photo/phono/osmophobia) with dizziness or unsteadiness.
- Refer to SWL migraine guidelines
Light headedness, postural hypotension / syncope postural drop of more than 20 mmHg
- Treat using a conservative approach, review medications and lifestyle measures.
- If no improvement consider referral to Cardiology.
Possible Meniere’s Disease
- Severe Vertigo (recurrent), tinnitus (roaring), fluctuating low frequency hearing loss, preceding aural pressure common, episodes lasting minutes to hours.
- Treatment using vestibular sedatives may be useful in acute episode. Low salt diet, caffeine and alcohol reduction,
- Supportive advice of remaining mobile to assist compensation.
- If greater than one episode refer to audiology.
Clinical Red Flags
Cardiac
- Any associated chest pain or difficulty breathing refer urgently to emergency department.
- Cardiac arrhythmias,
- Structural heart disease:
- abnormal ECG,
- family history of sudden death,
- known coronary vascular disease,
- blackouts,
- dizziness/syncope during exercise refer urgently to cardiology
Neurology
Acute continuous vertigo plus new headache, severe headache or neck pain, unable to stand or sit-up unaided, focal weakness or paresthesia of face or limbs, the 5 D’s: Dysarthria, Dysphonia, Diplopia, Dysphagia, Dysmetria, spontaneous vertical nystagmus at rest (not during positional manoeuvre), deafness and cerebellar signs. If one of more of these symptoms refer urgently to the stroke.
ENT
- Sudden deafness refer urgently to ENT.
References
Guidance approved by Integrated Medicines Committee (IMOC) March 2025