Patient handout

Acute Vestibular Syndrome (HINTS pivot for central vs peripheral)

PRODUCTION

1. Your condition

This handout is for acute vestibular syndrome (hints pivot for central vs peripheral). Your care team identified this based on: continuous vertigo + nausea/vomiting + gait unsteadiness + nystagmus × ≥24 h (avs definition; hotson/baloh nejm 1998 pmid 9725927; tarnutzer cmaj 2011 pmid 21576300).

Other reasons your team may use this plan: acute new vertigo in patient with vascular risk factors (age>60, htn, dm, smoking, af, anticoag) — posterior-circulation stroke risk (kattah stroke 2009 pmid 19762709); vertigo + sudden sensorineural hearing loss — aica-territory stroke until proven otherwise; hints-plus pivot (newman-toker acad emerg med 2013 pmid 24127701); vertigo + severe occipital headache / neck pain — vertebral artery dissection trigger (grace-3 edlow acad emerg med 2023 pmid 37166022).

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — recovering

If you have:

steady_improvement_each_day
no_new_neuro_symptoms
completing_steroid_taper
vestibular_rehab_engaged

Do this:

Continue steroid taper as prescribed; do not stop abruptly
Attend vestibular rehab — keep doing exercises even when dizzy
Stop the meclizine / antihistamine when no longer severely vertiginous (>3-5 d delays recovery)
No driving until medically cleared

YELLOW — Caution — call ENT / neurology / primary same day

If you have:

no_improvement_at_48_72h
new_hearing_loss_or_tinnitus
recurrent_vertigo_episodes
persistent_imbalance_>2wk
glucose_>200_on_steroid

Do this:

Call ENT / neurology clinic same day
Continue medications as prescribed unless told otherwise
Schedule an audiogram if any hearing change

RED — Emergency — call 911 / go to ED

If you have:

new_weakness_or_numbness_face_arm_leg
new_speech_problem_or_difficulty_swallowing
new_double_vision_or_vision_loss
sudden_complete_hearing_loss
worst_ever_headache_or_neck_pain
loss_of_consciousness_or_drop_attack

Do this:

Call 911 / go to nearest ED
This may be a stroke even if you were told it was vestibular neuritis
Bring medication list

Call your provider if:

After any ED visit so neurology / ENT can update plan

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Any central HINTS feature: normal head impulse OR direction-changing nystagmus OR skew deviation positive (Kattah Stroke 2009 PMID 19762709)(life-threatening)
Sudden sensorineural hearing loss + AVS — AICA-territory stroke pivot (Newman-Toker Acad Emerg Med 2013 PMID 24127701)(life-threatening)
Severe occipital headache or neck pain + AVS — vertebral artery dissection trigger (GRACE-3 PMID 37166022)
HINTS exam uninterpretable (untrained clinician, intolerant patient, ongoing vomiting) (Edlow GRACE-3 PMID 37166022)
Drop attacks, transient diplopia, dysarthria, dysphagia, hemianopia, or limb ataxia preceding / accompanying vertigo (Hotson/Baloh NEJM 1998 PMID 9725927)
Chronic alcohol use OR hyperemesis gravidarum OR bariatric surgery OR refeeding + AVS-like presentation (Hotson/Baloh NEJM 1998 PMID 9725927)

5. Follow-up

Vestibular-rehab 4-6 wk; ENT for persistent vertigo / hearing loss / Meniere features; neurology for recurrent vertigo with red flags / migraine features / suspected demyelination; fall-risk assessment + home-safety in elderly; driving counselling per jurisdiction (GRACE-3 PMID 37166022; Hotson/Baloh NEJM 1998 PMID 9725927)

6. Sources

Guideline: 2023 SAEM GRACE-3 (Edlow et al, Acad Emerg Med) + Kattah HINTS (Stroke 2009) + Newman-Toker HINTS-plus (Acad Emerg Med 2013) + Strupp methylprednisolone (NEJM 2004)