Vertigo the Big 3

Every ‘heart sink list‘ includes the ‘feeling a bit dizzy, doc‘ presentation. Even with the semantic AI diagnostology probe ramped up to 11…’dizzy‘ remains a word reticent to reveal it’s true identity, until it is too late…

Fear not, for Dr Peter Johns, Canadian emergency physician and dizziness demystifier, has made a video on how to diagnose ‘The Big 3 of Vertigo” in the Emergency Department

The big 3 of vertigo: BPPV; Vestibular neurits; an Cerebellar stroke

Summary:  The Big 3 of Vertigo

Dr Johns advocates an organized approach. If there are concerning neurological features; severe head or neck pain; or the patient is unable to stand, they warrant a CT scan and an inpatient stay.

Patients whose vertigo is initiated by movement and only lasts less than 2 minutes at a time are most likely suffering from benign paroxysmal positional vertigo (BPPV) and would benefit from a Dix-Hallpike test followed by treatment with an Epley maneuver.

It is important to note that patients with BPPV do not have nystagmus at rest, also  HINTS+ testing is not indicated in this population (reserved for patients with hours or days of vertigo at rest).

In the presence of horizontal canal BPPV on the Dix-Hallpike test, the Gufoni maneuver is advised. HINTS+ testing is not indicated in this population (reserved for patients with hours or days of continuous vertigo.)

Patients with protracted vertiginous symptoms (hours to days) warrant a HINTS+ examination and in the presence of positive features they require imaging and admission to look for a CVA.

There are four components of the HINTS+ exam and each component has either a ‘central’ or ‘peripheral’ result. If any of the components tested have a positive central result, the result is described as HINTS+ central.

Test of skewNO vertical skewVertical
Head Impulse TestAbnormalNormal
+ Bedside test of hearingNO new lossNew loss

If none of the HINTS+ exam point to a central cause then the patient has vestibular neuritis and may be safely discharged.

Further Reading


Neurological Mind-boggler

Dr Tom Cassidy MBBS FACEM. Emergency physician, Perth Australia. Father of two humans and whimsical lyricist. Special skills: relocating ECGs, reading toxidromes and interpreting dislocations | @tgpcassidyLinkedIn |


  1. Hi Tom, thanks for featuring my approach.

    It’s very important for clinicians to realize that patients with BPPV don’t have nystagmus at rest, and that you can’t use HINTS + exam unless the patient has nystagmus at rest. If you could edit it to include these points, it will prevent a lot of confusion.

    Thanks again,

    Peter Johns

    Ottawa, Canada

  2. 🌸AICA strokes or TIA can mimik like Meniere’s


    🌸PICA strokes can mimik like


    acute unilateral vestibulopathy.

    🌸The most important clue, I think is

    Vascular risk factors
    *Inability to stand*
    Swaying to side with eyes open
    Especially I find that

    *Inability to stand*, tandem gait are really helpful to diagnose a central lesion vs peripheral!

    We can make it HINTSS plus

    The second S for standing!

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.