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symptom.vertigo.v1PRODUCTION
symptom.vertigo.v1

Vertigo (acute / recurrent)

symptomacutesubacuteundifferentiatedadult
Hard-required inputs
0 / 13
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm vertigo (illusion of motion) vs presyncope / disequilibrium / lightheadedness (AAN 2024); episodic vs continuous; positional vs spontaneous; first vs recurrent

Inputs
2
Actions
0
Advance rule
Set
Advance when

vertigo character + temporal pattern established

Patient inputs (20)

Age >60 = higher prior for posterior circulation stroke (AHA/ASA 2021 PMID 34024117) and BPPV (AAO-HNS 2017 PMID 28248609)

Vestibular migraine and Meniere skew female (Bárány 2015 PMID 23532572; AAO-HNS 2020 PMID 32267799)

Orthostatic vitals to differentiate presyncope from true vertigo; supine + standing measurements (AAN 2024)

Orthostatic delta; bradyarrhythmia and AF mimic vertigo (AAN 2024); AF screen if cryptogenic posterior infarct (CRYSTAL-AF Sanna NEJM 2014)

Sudden SNHL + vertigo = AICA stroke vs Meniere (AAO-HNS 2020) vs labyrinthitis vs SSNHL (AAO-HNS 2019 PMID 31369359)

HTN, DM, AF, smoking, prior stroke/TIA, hyperlipidemia shifts prior to central (AHA/ASA 2021 PMID 34024117)

Aminoglycosides, loop diuretics, cisplatin, salicylates (ototoxic — AAO-HNS 2024); antihypertensives (orthostatic); benzodiazepines / meclizine (AGS Beers 2023)

Seconds (BPPV — AAO-HNS 2017) vs minutes-hours (vestibular migraine — Bárány 2015) vs hours-days (Meniere — AAO-HNS 2020 / neuritis / stroke)

Position-evoked = BPPV until proven otherwise; latency 1-5 s after position change with torsional up-beating nystagmus (AAO-HNS 2017 PMID 28248609)

Hypoglycemia / hyperglycemia mimics; correct before treating as code stroke

Vertebral artery dissection — neck pain + posterior circulation deficit, often after trauma or chiropractic manipulation (AHA/ASA 2021 PMID 34024117)

Truncal ataxia disproportionate to vertigo = central lesion / cerebellar pathology (Newman-Toker Stroke 2009 PMID 19762709)

Diplopia, dysarthria, hemiparesis, hemisensory loss, dysphagia → central until proven otherwise (AHA/ASA 2021)

MRI DWI confirms posterior circulation infarct — INSENSITIVE in first 24-48 h (Newman-Toker Stroke 2009 PMID 19762709; HINTS+ outperforms early MRI: HINTS sens 97% vs MRI <50% at <48 h)

STAT CTA/MRA neck for vertebral artery dissection (AHA/ASA 2021)

Sensorineural pattern in Meniere (AAO-HNS 2020 PMID 32267799); sudden SNHL needs urgent steroid (AAO-HNS 2019 SSNHL PMID 31369359)

Meniere triad component (AAO-HNS 2020 PMID 32267799); cochleovestibular pattern

Vestibular migraine criterion (Bárány Society 2015 PMID 23532572) — ≥5 episodes + ≥50% with migraine features

Vestibular neuritis post-URI (1-2 wk latency); labyrinthitis if + hearing loss (Strupp NEJM 2004 PMID 15269315)

Vertebral artery dissection precipitant (AHA/ASA 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (12)

12 need judgement
  • informationallife_threateninghints_central_pattern
    HINTS+ central pattern: normal head impulse + direction-changing nystagmus + skew deviation (Newman-Toker Stroke 2009 PMID 19762709) — sens 100% / spec 96% for posterior circulation stroke; LR+ ~6.0 for central
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningvertebral_artery_dissection
    Vertigo + new neck pain + posterior circulation deficit, often after trauma / chiropractic manipulation / strenuous neck motion (AHA/ASA 2021 PMID 34024117)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcerebellar_hemorrhage_infarct
    Truncal ataxia disproportionate to vertigo, severe headache, declining LOC, brainstem signs → cerebellar hemorrhage or infarct with mass effect on STAT non-contrast CT (AHA/ASA 2021)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresudden_snhl_with_vertigo
    Sudden SNHL >30 dB at ≥3 contiguous frequencies within 72 h + vertigo — AICA territory infarct vs labyrinthitis vs Meniere onset (AAO-HNS 2019 SSNHL CPG PMID 31369359)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehints_peripheral_pattern
    HINTS+ peripheral pattern: positive (abnormal) head impulse + unidirectional horizontal nystagmus + no skew (Newman-Toker 2009) — LR+ ~0.02 against central (effectively rules out posterior stroke when AVS criteria met)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemeniere_triad
    Meniere disease triad: ≥2 spontaneous vertigo attacks 20 min - 12 h + sensorineural hearing loss documented audiometrically (low-mid frequency) + tinnitus / aural fullness (AAO-HNS 2020 PMID 32267799)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatevestibular_migraine
    Bárány Society 2015 vestibular migraine criteria: ≥5 episodes vertigo 5 min - 72 h + current or prior migraine + ≥50% of episodes with migraine features (headache + photophobia + phonophobia + visual aura) (Bárány 2015 PMID 23532572)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepersistent_vertigo_with_dehydration
    Severe persistent vertigo + intractable vomiting + dehydration / acute kidney injury (AAN 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateelderly_on_meclizine_or_benzo
    Elderly patient (≥65) on chronic meclizine or benzodiazepine for vertigo (AGS Beers 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemeniere_progressive_hearing_loss
    Meniere with progressive sensorineural hearing loss despite first-line therapy (AAO-HNS 2020 PMID 32267799)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildbppv_posterior_canal_dix_hallpike
    Dix-Hallpike positive with up-beating torsional nystagmus + 1-5 s latency + fatigability + brief duration (<60 s) (AAO-HNS 2017 PMID 28248609) — posterior-canal BPPV
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildbppv_horizontal_canal_supine_roll
    Supine roll test positive with geotropic or apogeotropic horizontal nystagmus (AAO-HNS 2017) — horizontal-canal BPPV
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

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Recommended regimen

Acute vertigo symptomatic management (≤72 h, peripheral) (AAO-HNS 2017 + AAN 2024)
axis: vertigo_acute_symptomatic
Selected axis "Acute vertigo symptomatic management (≤72 h, peripheral) (AAO-HNS 2017 + AAN 2024)" by default fallback (first axis)
  • meclizine
    first line
    antihistamine_vestibular_suppressant
    25 mg • PO • q6-8h PRN ≤72 h (max: 100 mg/day)
    triggers: acute_peripheral_vertigo_severe
    Short-course only — chronic use delays vestibular compensation (AAO-HNS 2017 PMID 28248609); AGS Beers 2023 in elderly
    rxcui 6676
  • lorazepam
    second line
    benzodiazepine
    0.5-1 mg • PO/IV • q6-8h PRN ≤48 h
    triggers: severe_distressing_vertigo
    Limit to 48 h; falls and dependence risk; AGS Beers 2023 in elderly; delays vestibular compensation
    rxcui 6470
  • prochlorperazine
    add on
    D2_antagonist_antiemetic
    5-10 mg • PO/IM/IV • q6h PRN
    triggers: severe_nausea_vomiting
    Effective antiemetic; watch dystonia + QTc (AAN 2024)
    rxcui 8704
  • ondansetron
    add on
    5HT3_antagonist
    4-8 mg • PO/IV • q8h PRN
    triggers: severe_nausea_vomiting
    QTc precaution; preferred over droperidol (AAN 2024)
    rxcui 26225
  • prednisolone
    first line
    corticosteroid
    60 mg • PO • daily × 5 d then taper over 2 wk
    triggers: vestibular_neuritis_within_3_days_of_onset
    Strupp NEJM 2004 PMID 15269315 — improves caloric recovery; antivirals not routinely added
    rxcui 8638

outpatient playbook — drug actions (5)

  1. 1. Epley (office) + home Brandt-Daroff exercises
    N/A • manipulation • office Epley; Brandt-Daroff BID at home
    trigger: Recurrent posterior-canal BPPV
    AAO-HNS 2017 — Epley first-line; self-treatment with Brandt-Daroff if recurrent
  2. 2. sodium restriction + HCTZ + betahistine (tiered)
    Per axis • PO • daily / TID
    trigger: Definite Meniere with ≥2 attacks
    AAO-HNS 2020 PMID 32267799 stepwise management; lifestyle first, then diuretic, then betahistine
  3. 3. intratympanic dexamethasone
    4-10 mg/mL × 3 injections • intratympanic • weekly × 3
    trigger: Refractory Meniere after step 2
    AAO-HNS 2020 — hearing-preserving second-line; ENT-administered
  4. 4. intratympanic gentamicin
    20-30 mg titrated • intratympanic • series
    trigger: Unilateral refractory Meniere with serviceable contralateral hearing
    AAO-HNS 2020 — chemical labyrinthectomy; risk of hearing loss; reserve
  5. 5. vestibular migraine preventive (topiramate / propranolol / candesartan)
    Per migraine engine • PO • daily
    trigger: Bárány 2015 vestibular migraine criteria met
    Route to neuro.migraine.core.v1; topiramate / propranolol / venlafaxine commonly used (Bárány 2015 PMID 23532572)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Acute continuous vertigo + nausea + nystagmus + gait unsteadiness ≥24 h (Newman-Toker Stroke 2009 PMID 19762709 — HINTS+ indication); Brief vertigo provoked by head position change (AAO-HNS BPPV 2017 PMID 28248609 — Dix-Hallpike indication); Recurrent spontaneous vertigo episodes — Meniere (AAO-HNS 2020 PMID 32267799) / vestibular migraine (Bárány 2015 PMID 23532572).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Vertigo (acute / recurrent)** (symptom.vertigo.v1).
Phenotype framing: BPPV (AAO-HNS 2017 — ~20-30% of ED vertigo) / vestibular neuritis (~10-15%) / Meniere (AAO-HNS 2020) / labyrinthitis / posterior circulation stroke (AHA/ASA 2021 — ~3-5% ED / up to 25% ED-AVS) / vestibular migraine (Bárány 2015) / cerebellar lesion / ototoxicity / orthostatic / SSNHL+vertigo (AAO-HNS 2019) / vertebral dissection
Scope: Confirm vertigo (illusion of motion) vs presyncope / disequilibrium / lightheadedness (AAN 2024); episodic vs continuous; positional vs spontaneous; first vs recurrent

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute vertigo symptomatic management (≤72 h, peripheral) (AAO-HNS 2017 + AAN 2024)**.
1. meclizine 25 mg PO q6-8h PRN ≤72 h (antihistamine_vestibular_suppressant, first line) — Short-course only — chronic use delays vestibular compensation (AAO-HNS 2017 PMID 28248609); AGS Beers 2023 in elderly
2. lorazepam 0.5-1 mg PO/IV q6-8h PRN ≤48 h (benzodiazepine, second line) — Limit to 48 h; falls and dependence risk; AGS Beers 2023 in elderly; delays vestibular compensation
3. prochlorperazine 5-10 mg PO/IM/IV q6h PRN (D2_antagonist_antiemetic, add on) — Effective antiemetic; watch dystonia + QTc (AAN 2024)
4. ondansetron 4-8 mg PO/IV q8h PRN (5HT3_antagonist, add on) — QTc precaution; preferred over droperidol (AAN 2024)
5. prednisolone 60 mg PO daily × 5 d then taper over 2 wk (corticosteroid, first line) — Strupp NEJM 2004 PMID 15269315 — improves caloric recovery; antivirals not routinely added

Setting playbook (outpatient) — Long-term management of recurrent peripheral vertigo (BPPV, Meniere, vestibular migraine, vestibular neuritis recovery); reinforce vestibular rehab; identify central etiologies missed in ED; tiered Meniere escalation (AAO-HNS 2017 + 2020; Bárány 2015)
6. Epley (office) + home Brandt-Daroff exercises N/A manipulation office Epley; Brandt-Daroff BID at home — Recurrent posterior-canal BPPV (AAO-HNS 2017 — Epley first-line; self-treatment with Brandt-Daroff if recurrent)
7. sodium restriction + HCTZ + betahistine (tiered) Per axis PO daily / TID — Definite Meniere with ≥2 attacks (AAO-HNS 2020 PMID 32267799 stepwise management; lifestyle first, then diuretic, then betahistine)
8. intratympanic dexamethasone 4-10 mg/mL × 3 injections intratympanic weekly × 3 — Refractory Meniere after step 2 (AAO-HNS 2020 — hearing-preserving second-line; ENT-administered)
9. intratympanic gentamicin 20-30 mg titrated intratympanic series — Unilateral refractory Meniere with serviceable contralateral hearing (AAO-HNS 2020 — chemical labyrinthectomy; risk of hearing loss; reserve)
10. vestibular migraine preventive (topiramate / propranolol / candesartan) Per migraine engine PO daily — Bárány 2015 vestibular migraine criteria met (Route to neuro.migraine.core.v1; topiramate / propranolol / venlafaxine commonly used (Bárány 2015 PMID 23532572))

Non-pharmacologic actions:
- Vestibular rehab (AAO-HNS 2017 strong recommendation; Cochrane 2014 PMID 24492332)
- Audiology referral if Meniere (AAO-HNS 2020)
- Driving safety counseling
- Cochlear implant evaluation if profound SNHL post-Meniere
- Migraine trigger avoidance + lifestyle if vestibular migraine

AVOID / contraindication checks:
- Meclizine_avoid_chronic_or_in_elderly_BEERS
- Benzo_limit_48h_falls_BEERS_in_elderly
- Prochlorperazine_QT_dystonia
- Ondansetron_QT
- Steroid_avoid_if_uncontrolled_DM_or_active_infection

Monitoring

Regimen monitoring:
- symptom diary daily
- recheck at 3 d for vestibular neuritis
- audiometry if hearing change

Setting (outpatient) monitoring:
- Symptom diary
- Audiometry q6-12 mo for Meniere (AAO-HNS 2020)
- Annual review of meds — AGS Beers 2023 (taper meclizine, benzo)
- BP review (orthostatic mimics)

Follow-up plan: Vestibular rehab referral (AAO-HNS 2017 strong recommendation; Cochrane 2014); audiology q6-12 mo for Meniere; neurology if vestibular migraine (Bárány 2015 — route to neuro.migraine.core.v1); ENT for refractory Meniere
- Close-out criterion: referrals scheduled

Monitoring phase: Symptom diary, recurrence, audiometry follow-up if Meniere (AAO-HNS 2020); vestibular rehab progress; fall risk if elderly (AGS Beers 2023)

Disposition

Current setting: outpatient — Long-term management of recurrent peripheral vertigo (BPPV, Meniere, vestibular migraine, vestibular neuritis recovery); reinforce vestibular rehab; identify central etiologies missed in ED; tiered Meniere escalation (AAO-HNS 2017 + 2020; Bárány 2015)

Disposition criteria:
- Continue current axis if controlled
- Refer ENT/neurology if refractory
- Cochlear implant referral if profound bilateral SNHL

Escalation triggers (move to higher acuity):
- Progressive hearing loss → ENT urgently (AAO-HNS 2020)
- New focal neurology → stroke workup (AHA/ASA 2021)
- Refractory Meniere → ENT for intratympanic / surgical options
- NEW central feature (diplopia, dysarthria, hemiparesis) → ED

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] HINTS+ central pattern: normal head impulse + direction-changing nystagmus + skew deviation (Newman-Toker Stroke 2009 PMID 19762709) — sens 100% / spec 96% for posterior circulation stroke; LR+ ~6.0 for central
- [LIFE_THREATENING] Vertigo + new neck pain + posterior circulation deficit, often after trauma / chiropractic manipulation / strenuous neck motion (AHA/ASA 2021 PMID 34024117)
- [LIFE_THREATENING] Truncal ataxia disproportionate to vertigo, severe headache, declining LOC, brainstem signs → cerebellar hemorrhage or infarct with mass effect on STAT non-contrast CT (AHA/ASA 2021)

Citations

- AAO-HNS BPPV CPG (2017) + AAO-HNS Meniere CPG (2020) + AAO-HNS SSNHL CPG (2019) + Bárány Society 2015 vestibular migraine + Newman-Toker HINTS+ (Stroke 2009 / Neurology 2013) + AHA/ASA Stroke Prevention 2021 (posterior circulation) + Strupp NEJM 2004 (vestibular neuritis) + Cochrane Vestibular Rehab 2014 [PMID:19762709](https://pubmed.ncbi.nlm.nih.gov/19762709/)
- Cited evidence (PMID 24127701) [PMID:24127701](https://pubmed.ncbi.nlm.nih.gov/24127701/)
- Cited evidence (PMID 28248609) [PMID:28248609](https://pubmed.ncbi.nlm.nih.gov/28248609/)
- Cited evidence (PMID 32267799) [PMID:32267799](https://pubmed.ncbi.nlm.nih.gov/32267799/)
- Cited evidence (PMID 23532572) [PMID:23532572](https://pubmed.ncbi.nlm.nih.gov/23532572/)

Last reconciled with current guidelines: 2026-05-14.
References
  • AAO-HNS BPPV CPG (2017) + AAO-HNS Meniere CPG (2020) + AAO-HNS SSNHL CPG (2019) + Bárány Society 2015 vestibular migraine + Newman-Toker HINTS+ (Stroke 2009 / Neurology 2013) + AHA/ASA Stroke Prevention 2021 (posterior circulation) + Strupp NEJM 2004 (vestibular neuritis) + Cochrane Vestibular Rehab 2014 — PMID:19762709
  • Cited evidence (PMID 24127701) — PMID:24127701
  • Cited evidence (PMID 28248609) — PMID:28248609
  • Cited evidence (PMID 32267799) — PMID:32267799
  • Cited evidence (PMID 23532572) — PMID:23532572