Managing Dizziness in the ED: Practical Assessment and Recognition of High-Risk Conditions

Dizziness accounts for up to 15.4% of ED presentations and is a frequent, high‑stakes complaint; in the emergency department, missed posterior‑circulation stroke and other serious causes remain a persistent risk, so rapid, precise assessment is essential.

Immediate identification of high‑risk features reduces the chance of overlooked life‑threatening diagnoses and avoids unnecessary downstream testing. This update summarizes concise, actionable assessment strategies for ED clinicians managing undifferentiated dizziness.

Diagnostic stewardship and refined risk stratification now guide evaluation intensity. Clinicians should apply focused bedside strategies—timing‑and‑trigger history, targeted neurologic screening, orthostatic assessment, and selected maneuvers—to distinguish vestibular from central causes.

Detailed thorough history-taking and a focused physical exam substantially reduce diagnostic errors by revealing red flags beyond peripheral vestibular disorders. Sudden onset with maximal intensity at onset, associated diplopia, dysarthria, limb weakness, severe headache, vascular risk factors, and anticoagulation status all increase suspicion for central causes.

Checklist-style exam elements include gait and tandem-walking assessment; a brief cranial nerve screen (ocular alignment, extraocular movements, facial strength); a targeted neurologic exam for focal deficits; and orthostatic vitals with active‑stand testing when presyncope is in the differential. Documented focal neurologic signs prompt expedited workup; together these history and exam steps distinguish most high‑risk presentations from benign vestibular causes.

HINTS is a validated bedside algorithm for differentiating central from peripheral causes in patients with ongoing spontaneous vertigo and persistent nystagmus. The three components—Head‑Impulse (impulse test), evaluation of Nystagmus (pattern and direction), and Test‑of‑Skew (cover/uncover evaluation for vertical misalignment)—provide pragmatic triage for posterior‑circulation stroke when nystagmus is present and symptoms are continuous. When performed by trained examiners, HINTS outperforms early non‑contrast CT for detecting posterior‑circulation ischemia and approaches the sensitivity of early MRI.

Limitations include the need for experienced examiners, lack of validation for transient or positional dizziness, and the fact that a normal head‑impulse does not exclude all central causes; selective use is therefore advised when the clinical context and local training permit.

Many ED presentations are nonspecific and benefit from pairing risk stratification with diagnostic restraint. Red flags that mandate further workup include new focal neurologic deficits, persistent or progressive symptoms, unexplained syncope features, severe headache or neck pain, and high‑risk comorbidity such as atrial fibrillation, recent vascular events, or anticoagulation.

Routine imaging has limited yield for low‑risk, nonfocal dizziness and often does not change management; observation with targeted outpatient follow‑up, focused laboratory testing, ECG, point‑of‑care ultrasound, and serial reassessment optimizes resource use while preserving safety.

Combining focused risk stratification with measured diagnostic restraint improves ED throughput and reduces unnecessary testing without compromising detection of serious disease.

Key Takeaways:

• What’s new? Precise history and targeted bedside exam reduce missed central causes while avoiding routine, low‑yield testing.
• Who’s affected? Emergency clinicians and ED systems managing undifferentiated dizziness, with particular impact for patients with vascular risk factors and anticoagulation.
• What changes next? Prioritize timing‑and‑trigger history, targeted neurologic screening and orthostatic testing; use HINTS selectively when persistent nystagmus is present; reserve imaging for high‑risk findings; and arrange clear observation or outpatient follow‑up.