Dizzy: No more !

The approach to giddiness: thinking in syndromes, not symptoms

“Giddiness” is one of those ED complaints that feels deceptively benign—yet quietly carries the risk of missed posterior circulation stroke. Acute dizziness accounts for roughly 3–4% of ED visits, with nearly 1 in 5 patients admitted. Stroke remains uncommon, but consistently over-investigated with CT and under-diagnosed clinically.

The modern, evidence-based shift—crystallised in GRACE-3—is simple but profound: stop chasing symptom quality (“vertigo vs presyncope”) and start thinking in timing, triggers, eye movements, gait, and red flags (Edlow et al., 2023).

This post walks through a bedside-first, syndrome-based approach you can use on your next dizzy patient—without defaulting to CT or medications.

Before we start: what do patients mean by “giddiness”?

Before diving into algorithms, eye movements, and imaging decisions, it’s worth addressing the word that brings many patients to the ED in the first place: “giddiness.” In clinical practice, patients use dizzy, giddy, woozy, light-headed, off-balance, or spinning interchangeably—and often change their description within the same conversation (Sloane et al., 2001; Broomfield et al., 2008; Sommerfeldt et al., 2020).

Research consistently shows that these labels overlap heavily and have poor diagnostic reliability, which is why modern guidelines advise clinicians not to anchor on the word itself but instead focus on timing, triggers, associated symptoms, eye movements, and gait (Edlow et al., 2018; Gurley & Edlow, 2019; Muncie et al., 2017).

In many ENT and clinical literature, “giddiness” is simply used as a broad umbrella term for dizziness or vertigo rather than a distinct entity (Ranjan et al., 2020; Ramchandra, 2021; Thomas et al., 2018). With that context, the section below clarifies how these terms are used—and why, in the ED, the word matters far less than the bedside exam that follows.

Why “giddiness” is hard in the ED

Dizzy patients are heterogeneous, time-consuming, and cognitively taxing. About 10% have a neurological cause, and one-third of those are cerebrovascular (Edlow et al., 2023; Nouini et al., 2023).

Traditional teaching tried to subtype dizziness by patient-described quality—vertigo, presyncope, disequilibrium, light-headedness. Multiple studies now show this performs poorly and often misleads clinicians (Edlow et al., 2023; Tarnutzer et al., 2025).

GRACE-3 reframes dizziness as a single symptom and recommends classification by:

• Timing

• Triggers

• Associated signs (especially eye movements and gait)

Think of eye movements and gait as vital signs of the posterior fossa.

Step 1: Frame the presentation (TiTrATE) + red flags

Use the TiTrATE approach to classify dizziness into one of three syndromes (Edlow et al., 2023; Stewart et al., 2022; Tarnutzer et al., 2025):

1. Triggered episodic (seconds–minutes, positional)

2. Acute vestibular syndrome (AVS) (continuous ≥24 h)

3. Spontaneous episodic (recurrent, untriggered)

At the same time, screen aggressively for red flags:

• New focal neurological deficits

• Severe gait or truncal ataxia

• New headache or neck pain (consider vertebral dissection)

• Multiple vascular risk factors

• Inability to sit or stand independently

Roughly one-third of neurological dizziness is cerebrovascular, so this screen matters (Edlow et al., 2023; Gerlier et al., 2025; Ota et al., 2023).

Step 2: Exclude obvious medical causes

Up to half of dizzy ED patients have systemic causes:

• Drug toxicity

• Hypovolaemia/anaemia

• Sepsis

• Arrhythmia

• Metabolic derangements - like hypoglycaemia, dehydration, etc.

A focused history, vitals, ECG, glucose, and targeted labs often identify this group (Ota et al., 2023; Nouini et al., 2023).
If a clear medical diagnosis explains symptoms and no neurological red flags or concerning ataxia are present, manage the medical problem and reassess.

Step 3: Recognise the vestibular syndrome

a). Triggered episodic vestibular syndrome (t-EVS)

This is the most common vestibular pattern in the ED.

Key features

• Brief episodes (seconds–minutes)

• Clearly triggered by head position

• Severe symptoms stop completely when still

Think BPPV first.

Bedside diagnosis

• Dix–Hallpike → posterior canal BPPV

• Supine roll test → horizontal canal BPPV

Treatment

• Treat immediately with canalith repositioning (Epley/Gufoni)

• This reduces imaging, ED length of stay, and revisits (Edlow & Kerber, 2022; Gerlier et al., 2025; Stewart et al., 2022)

—> Typical BPPV needs no CT or MRI.

b). Acute vestibular syndrome (AVS)

AVS = continuous dizziness/vertigo, nausea, postural instability, usually with spontaneous nystagmus.

Two clinically important subgroups:

• True AVS: continuous symptoms with spontaneous nystagmus

• Pseudo-AVS: continuous dizziness without spontaneous nystagmus

True AVS (only indication for HINTS )

• If trained, perform HINTS/HINTS+

  • Peripheral pattern → vestibular neuritis likely

  • Central or equivocal → MRI >>> CT

• HINTS+ outperforms early MRI in the first 24–48 h when used correctly (Edlow et al., 2023; Tarnutzer et al., 2025)

Pseudo-AVS

• HINTS is not validated

• Any new gait ataxia is concerning

• Central causes must be excluded unless a clear medical explanation exists

Imaging pearl

• Early MRI can be false-negative in up to 20% within 24–48 h

• Use imaging as confirmation, not replacement, for bedside assessment (Edlow et al., 2023).

A critical note on HINTS: powerful, but only in the right hands and the right patients

Because HINTS is often described as being “more sensitive than MRI,” it has acquired an almost mythic status in emergency medicine. That reputation, however, only holds within a very narrow clinical niche. The evidence is remarkably consistent: HINTS is highly accurate only when applied to patients with true acute vestibular syndrome (AVS) and when performed by clinicians trained in neuro-otologic examination (Kattah, 2018; Ohle et al., 2020; Gottlieb et al., 2022).

In practice, this nuance is frequently lost. Multiple ED studies show that HINTS is commonly performed in patients without continuous symptoms, without spontaneous nystagmus, or with positional dizziness, where it was never intended to be used. In these populations, its diagnostic performance collapses, creating false reassurance or unnecessary alarm (Dmitriew et al., 2020; Nolan et al., 2025; Akhter et al., 2023).

When is HINTS actually useful?

HINTS should be reserved for a very specific clinical phenotype:

• Continuous dizziness/vertigo lasting hours to days

• Spontaneous nystagmus present at rest (after removing fixation)

• Gait unsteadiness

• No obvious alternative explanation such as intoxication, hypoglycaemia, or sepsis

This is the classic acute vestibular syndrome (AVS) population in which HINTS was derived and validated (Kattah, 2018; Gerlier et al., 2021; Loureiro et al., 2021).

ED data are sobering:

• In one large retrospective cohort, 96.9% of HINTS exams were performed in patients who did not meet AVS criteria, rendering the test essentially useless (Dmitriew et al., 2020).

• Other studies show ~70% inappropriate use, most commonly in patients without nystagmus, a group in whom HINTS has no evidentiary basis (Nolan et al., 2025; Akhter et al., 2023).

Using HINTS outside AVS blurs it with Dix–Hallpike populations, inflates false positives, and undermines its credibility altogether (Kattah, 2019; Loureiro et al., 2021).

What this means for ED practice?

• Population matters more than the test itself: HINTS is not a “dizziness exam”; it is an AVS exam with spontaneous nystagmus.

• Training is non-negotiable: surveys consistently show most frontline clinicians feel under-trained and lack confidence in interpreting eye movements (Warner et al., 2021; Nakatsuka & Molloy, 2022; Rehman et al., 2025).

• HINTS does not replace imaging outside its niche: transient symptoms, episodic dizziness, nystagmus-negative patients, or untrained examiners should prompt alternative pathways, often including MRI when central disease is a concern (Srinivasan & Tirschwell, 2023; Tarnutzer & Edlow, 2023).

This video by Dr Peter - shows correct way to perform it.

c). Spontaneous episodic vestibular syndrome (s-EVS)

Recurrent, untriggered episodes of dizziness/vertigo.

Key differentials

• Vestibular migraine

• Posterior circulation TIA

• Menière disease

• Episodic arrhythmia or PE

If vascular concern exists, pursue CTA/MRA, not non-contrast CT, and manage via stroke/TIA pathways (Vanni et al., 2024; Kozlowski et al., 2025).

Bedside ED algorithm - Life on the frontline©

Sudbury Vertigo Risk Score - some insights

The Sudbury Vertigo Risk Score (SVRS) is a 7-item bedside clinical tool designed for emergency departments to estimate the risk that dizziness or vertigo is due to a serious central cause such as stroke, TIA, vertebral artery dissection, or brain tumor (Ohle et al., 2024; Van Patot et al., 2025). It incorporates male sex, age >65, diabetes, hypertension (heavily weighted), focal motor or sensory deficits, cerebellar signs such as ataxia or dysmetria, and a protective deduction for clear benign paroxysmal positional vertigo (BPPV) (Ohle et al., 2024). In derivation and validation cohorts including more than 6,000 patients, the SVRS demonstrated excellent discriminatory performance (C-statistic ~0.95–0.96), with patients scoring <5 having nearly 0% risk of serious diagnoses and 100% sensitivity, while risk increased substantially with higher scores (Ohle et al., 2024; Van Patot et al., 2025).

How to use it: The SVRS should be calculated after a focused history and thorough neurological examination. Patients with scores <5 may be considered low risk and potentially discharged without advanced imaging if clinically stable, whereas scores ≥5 should prompt further investigation with neuroimaging and/or neurology consultation based on the overall clinical picture (Ohle et al., 2024).

When to use it: It is most useful in adult ED patients presenting with dizziness, vertigo, or imbalance when differentiating peripheral from possible central causes is uncertain (Van Patot et al., 2025).

When not to use it: The score should not replace clinical judgment and should not be applied in patients with clear stroke syndromes, unstable vital signs, altered mental status, or when a reliable neurological exam cannot be performed. Concerns have also been raised about diagnostic complexity and overreliance on risk scores alone (Günay et al., 2025).

Take-home message

Giddiness in the ED should no longer trigger reflex CT and meclizine.
Instead, anchor your approach in:

• Syndromes (TiTrATE)

• Bedside eye movements and gait

• Selective, purposeful imaging

• Early curative treatment for BPPV

This is how we miss fewer strokes while doing less harm.

“Educational caution: This framework is for education and bedside reasoning and does not replace clinical judgment, formal training, or local stroke pathways.”

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