Dizziness Red Flag Screener
Run this checklist on EVERY patient presenting with new or acute dizziness before attributing it to a benign peripheral cause.
🚨 Immediate Red Flags — Neuroimaging + Neurology Now
Any ONE of the following warrants urgent MRI brain (CT is insufficient for posterior fossa):
| Red Flag |
Why It Matters |
| Severely ataxic gait — patient staggers, falls, or cannot walk |
Cerebellar stroke until proven otherwise |
| Skew deviation (vertical misalignment of eyes) |
Highly specific for central vestibular lesion |
| Direction-changing nystagmus |
Central sign; peripheral nystagmus is unidirectional |
| Purely vertical or purely torsional nystagmus |
Cannot be explained by peripheral vestibular disease |
| Nystagmus NOT suppressed by visual fixation |
Peripheral nystagmus is suppressed; central is not |
| Abnormal HINTS exam in acute prolonged vertigo |
Direction-changing nystagmus OR no corrective saccade on head impulse OR skew deviation |
| New brainstem signs: diplopia, dysarthria, dysphagia, facial numbness, Horner syndrome |
Brainstem stroke or demyelination |
| New limb weakness, sensory deficit, or incoordination |
Central lesion |
| Severe occipital / neck headache with acute vertigo |
Vertebral artery dissection or posterior fossa haemorrhage |
| Sudden onset hearing loss + acute vertigo |
Labyrinthine infarct — vascular emergency |
⚠️ Concerning Features — Urgent Workup Required (Same Day / Next Day)
| Feature |
Consider |
| Atypical Dix-Hallpike: immediate onset, non-fatiguing, duration >1 min, minimal vertigo |
Posterior fossa lesion; MRI brain |
| Acute prolonged vertigo + any abnormal neuro finding |
Central pathology |
| Dizziness in setting of new cardiac arrhythmia or palpitations |
Cardiac cause; ECG, Holter |
| Dizziness while lying down (not positional) |
Cardiac arrhythmia; ECG |
| Acute dizziness + orthostatic hypotension + new medication |
Drug-induced; medication review + orthostatic vitals |
| First episode of severe vertigo in patient >60 with vascular risk factors |
Posterior circulation TIA/stroke; urgent MRI + vascular imaging |
| Progressive imbalance over weeks (not acute) |
CNS mass lesion, cerebellar degeneration |
✅ Reassuring (Low-Risk) Features
The following features together suggest a benign peripheral aetiology:
- Unidirectional nystagmus, suppressed by fixation
- Typical Dix-Hallpike response (2–20s latency, <1 min duration, fatigues, severe vertigo)
- Normal neurologic examination (gait, cranial nerves, coordination)
- No new brainstem or cerebellar symptoms
- Dizziness worsened by head movement (vestibular pattern)
- Associated unilateral hearing loss / tinnitus (suggests peripheral labyrinthine cause)
Quick HINTS Exam (for Acute Prolonged Severe Vertigo)
Perform when the patient has acute, prolonged, severe dizziness that has NOT resolved:
| Test |
Peripheral result |
Central result |
| H — Head Impulse Test |
Corrective saccade present (abnormal VOR) |
No corrective saccade (normal-appearing VOR) |
| I — Nystagmus direction |
Unidirectional |
Direction-changing |
| TS — Test of Skew |
No skew deviation |
Skew deviation present |
✅ All three peripheral = vestibular neuritis (benign)
🚨 Any single central result = neuroimaging urgently
⚠️ HINTS is only valid in acute continuous vertigo — do not apply to episodic or resolved dizziness.
Clinical Guardrails
- Normal MRI in first 24–48h does NOT exclude posterior fossa stroke — DWI sensitivity is ~80% in the first 24 hours for cerebellar/brainstem infarcts. If clinical suspicion is high, repeat MRI at 48–72h or discuss with neurology.
- HINTS exam requires training — if you are not confident performing it, default to neuroimaging in any acute prolonged vertigo with vascular risk factors.
- Dizziness alone can be the only presentation of a posterior circulation stroke — do not require other neurologic signs to be present before imaging.
- Older patients with vascular risk factors (hypertension, diabetes, AF, prior TIA/stroke) have a much higher prior probability of central cause — lower your threshold for imaging.
- Drug-induced dizziness is common and remediable — always review the medication list (antihypertensives, antidepressants, anticonvulsants, anticholinergics, vestibulotoxic drugs).
Source: Barton JS. "Approach to the patient with dizziness." UpToDate. Last updated Dec 11, 2025.
1---2name: dizziness-red-flag-screener3description: Dizziness Red Flag Screener4---56# Dizziness Red Flag Screener78> Run this checklist on EVERY patient presenting with new or acute dizziness before attributing it to a benign peripheral cause.910---1112## 🚨 Immediate Red Flags — Neuroimaging + Neurology Now1314Any ONE of the following warrants urgent MRI brain (CT is insufficient for posterior fossa):1516| Red Flag | Why It Matters |17|---|---|18| Severely ataxic gait — patient staggers, falls, or cannot walk | Cerebellar stroke until proven otherwise |19| Skew deviation (vertical misalignment of eyes) | Highly specific for central vestibular lesion |20| Direction-changing nystagmus | Central sign; peripheral nystagmus is unidirectional |21| Purely vertical or purely torsional nystagmus | Cannot be explained by peripheral vestibular disease |22| Nystagmus NOT suppressed by visual fixation | Peripheral nystagmus is suppressed; central is not |23| Abnormal HINTS exam in acute prolonged vertigo | Direction-changing nystagmus OR no corrective saccade on head impulse OR skew deviation |24| New brainstem signs: diplopia, dysarthria, dysphagia, facial numbness, Horner syndrome | Brainstem stroke or demyelination |25| New limb weakness, sensory deficit, or incoordination | Central lesion |26| Severe occipital / neck headache with acute vertigo | Vertebral artery dissection or posterior fossa haemorrhage |27| Sudden onset hearing loss + acute vertigo | Labyrinthine infarct — vascular emergency |2829---3031## ⚠️ Concerning Features — Urgent Workup Required (Same Day / Next Day)3233| Feature | Consider |34|---|---|35| Atypical Dix-Hallpike: immediate onset, non-fatiguing, duration >1 min, minimal vertigo | Posterior fossa lesion; MRI brain |36| Acute prolonged vertigo + any abnormal neuro finding | Central pathology |37| Dizziness in setting of new cardiac arrhythmia or palpitations | Cardiac cause; ECG, Holter |38| Dizziness while lying down (not positional) | Cardiac arrhythmia; ECG |39| Acute dizziness + orthostatic hypotension + new medication | Drug-induced; medication review + orthostatic vitals |40| First episode of severe vertigo in patient >60 with vascular risk factors | Posterior circulation TIA/stroke; urgent MRI + vascular imaging |41| Progressive imbalance over weeks (not acute) | CNS mass lesion, cerebellar degeneration |4243---4445## ✅ Reassuring (Low-Risk) Features4647The following features together suggest a benign peripheral aetiology:4849- Unidirectional nystagmus, suppressed by fixation50- Typical Dix-Hallpike response (2–20s latency, <1 min duration, fatigues, severe vertigo)51- Normal neurologic examination (gait, cranial nerves, coordination)52- No new brainstem or cerebellar symptoms53- Dizziness worsened by head movement (vestibular pattern)54- Associated unilateral hearing loss / tinnitus (suggests peripheral labyrinthine cause)5556---5758## Quick HINTS Exam (for Acute Prolonged Severe Vertigo)5960Perform when the patient has acute, prolonged, severe dizziness that has NOT resolved:6162| Test | Peripheral result | Central result |63|---|---|---|64| **H** — Head Impulse Test | Corrective saccade present (abnormal VOR) | No corrective saccade (normal-appearing VOR) |65| **I** — Nystagmus direction | Unidirectional | Direction-changing |66| **TS** — Test of Skew | No skew deviation | Skew deviation present |6768> ✅ All three peripheral = vestibular neuritis (benign)69> 🚨 Any single central result = neuroimaging urgently7071> ⚠️ **HINTS is only valid in acute continuous vertigo** — do not apply to episodic or resolved dizziness.7273---7475## Clinical Guardrails7677- **Normal MRI in first 24–48h does NOT exclude posterior fossa stroke** — DWI sensitivity is ~80% in the first 24 hours for cerebellar/brainstem infarcts. If clinical suspicion is high, repeat MRI at 48–72h or discuss with neurology.78- **HINTS exam requires training** — if you are not confident performing it, default to neuroimaging in any acute prolonged vertigo with vascular risk factors.79- **Dizziness alone can be the only presentation of a posterior circulation stroke** — do not require other neurologic signs to be present before imaging.80- **Older patients with vascular risk factors** (hypertension, diabetes, AF, prior TIA/stroke) have a much higher prior probability of central cause — lower your threshold for imaging.81- **Drug-induced dizziness** is common and remediable — always review the medication list (antihypertensives, antidepressants, anticonvulsants, anticholinergics, vestibulotoxic drugs).8283---8485*Source: Barton JS. "Approach to the patient with dizziness." UpToDate. Last updated Dec 11, 2025.*
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