Dizziness and lightheadedness are among the most common—but also most challenging—complaints in emergency medicine and general practice. They can arise from benign causes like dehydration or BPPV, but also from life-threatening conditions such as stroke, cardiac arrhythmias, severe anemia, or carotid artery dissection.
Your uploaded chart provides an excellent framework dividing dizziness into two main categories:
1. Lightheadedness / Presyncope2. Vertigo
Each category has different causes, exam techniques, and treatments.
This article explains everything in a clear, academic, student-friendly tone.
Red Flags in Dizziness
If present, these symptoms should immediately raise concern for dangerous pathology:
Major Red Flags
- Fever
- Severe headache
- Focal neurological weakness
- Altered mental status (AMS)
- Chest pain / shortness of breath / palpitations
- Dark stools (GI bleed)
- Diaphoresis
- Abnormal HiNTS exam (Head-Impulse, Nystagmus, Test of Skew)
These symptoms strongly increase the likelihood of stroke, cardiac disease, sepsis, anemia, or intracranial pathology.
First Step: Identify the Sensation
The chart asks the most important question:
Does the patient feel LIGHTHEADED or VERTIGO?
Lightheaded / presyncope = Circulatory or metabolic issue
(more common, but can be dangerous)
Vertigo = Vestibular issue
(central → dangerous, peripheral → common)
Lightheadedness / Presyncope
Lightheadedness feels like:
- “About to faint”
- “Cloudy”
- “Weak”
- “Drained”
- “Floating”
It is usually related to blood flow issues, cardiac abnormalities, anemia, infection, or low glucose.
A. Serious Causes (From Chart)
1. Cardiac causes (valve or arrhythmia)
History clues:
- CAD/CHF
- Palpitations
- Chest pain
- Shortness of breath
- Murmurs
Workup:
- EKG
- Troponins
- Continuous monitoring
Treatment:
- ASA if ACS suspected
- Admit for telemetry
2. Anemia
History clues:
- GI bleed (melena, hematemesis)
- Conjunctival pallor
Workup:
- CBC
- Coagulation tests
- Type & Screen
- FOBT
Treatment:
- Identify bleeding source
- Consider transfusion
3. Low glucose
History clues:
- Diabetes
- AMS
Workup:
Fingerstick blood glucoseTreatment:
- D50 IV or oral food
- Adjust diabetes meds
4. Infection
Elderly patients often present with dizziness due to infections.
Workup:
- UA
- CXR
- Lactate
Treatment:
- Fluid resuscitation
- Antibiotics
- Treat the source
B. Common Causes
1. Orthostatic hypotension
Clues:
- Dehydration
- New medications
- Lightheaded on standing
Workup:
Orthostatic vital signsTreatment:
- Fluids
- Adjust meds
2. Nonspecific lightheadedness
Sometimes related to infection, anxiety, or vasovagal episodes.
Workup: Exclusion
Treatment: Reassurance, fluids, treat underlying cause
Vertigo
Vertigo is the sensation that the room is spinning, often accompanied by nausea.
Vertigo is divided into:
- Peripheral (ear/vestibular; COMMON)
- Central (brainstem/cerebellum; DANGEROUS)
A. Peripheral Vertigo (Common Causes)
1. BPPV (Benign Paroxysmal Positional Vertigo)
Clues:
- Sudden, triggered by head movement
- Fatigable dizziness
- Short episodes
Workup:
Dix-Hallpike maneuverTreatment:
- Meclizine
- Epley maneuver (repositioning)
2. Labyrinthitis
Clues:
- Recent viral URI
- Hearing changes
Treatment:
- Meclizine
- ± Steroids
3. Ménière’s disease
Clues:
- Tinnitus
- Fluctuating hearing loss
Treatment:
- Meclizine
- HCTZ (diuretic)
B. Central Vertigo (Bad Causes)
Central causes are more serious and develop gradually.
1. Cerebrovascular Accident (Stroke) / Intracranial Hemorrhage
Clues:
- Nystagmus
- Ipsilateral facial numbness
- Weakness
Workup:
CT / MRITreatment:
Neurology consult2. Multiple Sclerosis
Clues:
- Young adults (20s–30s)
- Focal neurological signs
Workup:
MRITreatment:
Neurology follow-up3. Acoustic Neuroma
Clues:
Unilateral hearing lossWorkup:
MRITreatment:
Neurology / ENT4. Carotid Artery Dissection
Clues:
- Unilateral headache
- Neck pain
- Trauma history
Workup:
- CTA/MRA
- Ultrasound
Treatment:
- Anticoagulation
- Neurosurgery consult
Using the HiNTS Exam (Important for Students)
The HiNTS exam is a bedside tool to differentiate central vs peripheral vertigo in continuous symptoms.
HiNTS =
- Head Impulse
- Nystagmus
- Test of Skew
Abnormal HiNTS = Central cause (dangerous)
If positive → stroke until proven otherwise.
Documentation Essentials (From Chart)
HEENT
- Nystagmus
- Tympanic membranes
- Hearing exam
- Carotid bruits
Neuro
- Dysmetria
- Romberg
- Gait
- Cranial nerves
- Dix-Hallpike maneuver
Heart
- Murmurs
- Arrhythmia
Accurate documentation reduces missed strokes and cardiac issues.
Summary Tables for Quick Revision
Vertigo: Quick Overview
| Category | Condition | Key Clues | Workup | Treatment |
|---|---|---|---|---|
| Peripheral | BPPV | Positional | Dix-Hallpike | Epley, meclizine |
| Peripheral | Labyrinthitis | Recent URI | Clinical | Meclizine, steroids |
| Peripheral | Ménière’s | Tinnitus, hearing loss | Clinical | HCTZ |
| Central | Stroke/ICH | Nystagmus + focal signs | CT/MRI | Neuro consult |
| Central | MS | Young adult neuro sx | MRI | Neurology |
| Central | Acoustic neuroma | Unilateral hearing loss | MRI | Neuro/ENT |
| Central | Carotid dissection | Neck pain, trauma | CTA/MRA | Anticoag, neurosurgery |
Lightheadedness: Quick Overview
| Category | Condition | Key Clues | Workup | Treatment |
|---|---|---|---|---|
| Serious | Cardiac | CP/SOB/palps | EKG/troponins | Admit |
| Serious | Anemia | GI bleed | CBC | Transfusion |
| Serious | Hypoglycemia | DM | FSBG | D50 |
| Serious | Infection | Elderly | UA/CXR | Source control |
| Common | Orthostatic | Dehydration | Orthostatics | Fluids |
| Common | Nonspecific | Vasovagal | Exclusion | Reassure |
FAQs About Dizziness & Lightheadedness
1. What is the difference between dizziness and vertigo?
Vertigo feels like spinning; dizziness feels like faintness or imbalance.
2. When is dizziness an emergency?
When accompanied by weakness, headache, chest pain, or abnormal HiNTS exam.
3. Can vertigo be a stroke?
Yes—central vertigo can indicate cerebellar stroke.
4. Does BPPV cause hearing loss?
No. If hearing loss is present, think Ménière’s, acoustic neuroma, or labyrinthitis.
5. What causes lightheadedness after standing up?
Orthostatic hypotension.
6. Should all dizzy patients get imaging?
No—only those with red flags or central features.
