Dizziness sends millions of people to emergency departments each year. Most cases stem from benign inner ear problems, but some signal more serious neurological conditions.

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Why figuring out the cause of dizziness is so important.

The challenge with dizziness is that both inner ear problems and neurological conditions can feel very similar.

You might experience a spinning sensation, unsteadiness, or lightheadedness from displaced crystals in your inner ear or from a stroke affecting your brainstem or cerebellum.

This overlap is why your doctor must carefully check if the cause is peripheral (in your inner ear) or central (in your brain or brainstem). Finding certain clues can make a big difference in getting you the urgent treatment you may need.

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Red flags that suggest a neurological cause

Your doctor will look for specific "red flags" that suggest a serious central (brain) cause.

• New weakness or coordination problems. This includes weakness in an arm or leg, slurred speech (dysarthria), new clumsiness like being unable to touch your finger to your nose (dysmetria), or being very unsteady on your feet (ataxia). These are strong signs of a brain issue, like a stroke, even if they are mild or come and go.¹⁻³
• Abnormal eye movements. Your doctor will check for specific types of involuntary eye jerking (nystagmus). Signs of a brain problem include eyes jerking up and down (vertical nystagmus), eyes jerking in different directions depending on where you look, or if your eyes are misaligned vertically (skew deviation).¹ ² ⁴ ⁵
• Sudden, severe imbalance. If you suddenly feel so unsteady that you cannot stand or walk without help, you need an urgent evaluation. This is especially true for people over 60.¹ ³
• A cluster of "D" symptoms. Doctors get very concerned if dizziness happens along with any of these "deadly Ds":¹ ⁴ ⁵
  • Diplopia (double vision)
  • Dysarthria (slurred speech)
  • Dysphagia (difficulty swallowing)
  • Dysphonia (voice changes)
  • Dysmetria (clumsiness or lack of coordination)
  • Dysesthesia (abnormal sensations, like numbness or tingling)
• High stroke risk. Your doctor may use a scoring system (like the ABCD2 score) to check your overall stroke risk based on your Age, Blood pressure, Clinical symptoms, Duration of symptoms, and Diabetes. If you have a high score and are dizzy, you need an urgent assessment.¹ ⁴ ⁵

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The HINTS exam: A powerful bedside test

To figure out the cause of dizziness, trained doctors may use a powerful bedside test called the HINTS exam (Head Impulse, Nystagmus, Test of Skew).

• Head Impulse Test: Your doctor will ask you to focus on their nose while they perform a quick, small turn of your head. This tests your inner ear. If the test is normal (meaning your eyes stay locked on the target), it's surprisingly a red flag. It suggests the problem is in your brain, not your inner ear.
• Nystagmus (Eye Jerking): As mentioned earlier, your doctor looks for "dangerous" patterns of eye movement, like jerking that changes direction, goes up-and-down, or is purely rotational.
• Test of Skew: Your doctor will cover one of your eyes and then the other, checking to see if one eye is higher than the other. Any vertical misalignment (a "skew") points to a brain-based problem.

When done correctly, the HINTS exam can be extremely accurate—sometimes even better than an early MRI—at detecting a stroke in patients with sudden, persistent dizziness.¹⁻² ⁴⁻⁵

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How common medications can hide warning signs

You might be tempted to take an over-the-counter "dizziness" medication, such as meclizine (Antivert, Bonine), dimenhydrinate (Dramamine), or diphenhydramine (Benadryl). These are called vestibular suppressants and also include prescription drugs like diazepam (Valium) or lorazepam (Ativan).¹⁻⁶

While these drugs can reduce the spinning feeling, they also cause sleepiness. This makes it much harder for a doctor to find the subtle clues (like specific eye movements or unsteadiness) that are needed to tell an inner ear problem from a dangerous brain problem.¹⁻⁵

Using these medications too often can also slow down your brain's natural ability to recover.¹³⁶ The American Geriatrics Society specifically warns against using meclizine in older adults because its side effects can be confused with serious neurological symptoms.³

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When to seek immediate emergency care

Most dizziness is not an emergency. However, go to the emergency room immediately if you have dizziness along withany of the following:

• New weakness in your arm, leg, or one side of your face
• Slurred speech or trouble speaking
• Double vision
• Difficulty swallowing or voice changes
• Sudden, severe imbalance (cannot stand or walk without help)
• Any combination of these symptoms (e.g., dizziness plus slurred speech)
• A severe, sudden headache (often called a "thunderclap headache")
• Chest pain or shortness of breath
• Loss of consciousness (fainting)
• You have high-risk factors for stroke (like high blood pressure, diabetes, heart disease, or a previous stroke)

Don't ignore symptoms just because they are mild or seem to come and go. Even temporary neurological symptoms with dizziness can signal a stroke and need an urgent evaluation.

Be cautious with dizziness medications until a doctor has checked you. Taking a pill like meclizine before your evaluation might hide the very signs your doctor needs to see to make a correct diagnosis.⁶⁻¹⁰

Age matters. If you are over 60 and have new, severe dizziness and imbalance, seek prompt medical attention even if you don't have other obvious symptoms.¹ ³

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Getting an appropriate evaluation

If you go to the emergency department with dizziness, healthcare providers should conduct a thorough neurological examination, including assessments of eye movements, coordination, gait, and neurological function.

Be prepared to describe your symptoms clearly:

• Exactly when they started
• Whether the feeling is constant or in "episodes"
• What makes it better or worse
• Any other symptoms you're having at the same time

If you're experiencing concerning dizziness symptoms or have questions about its cause, our specialists at Neura can provide a comprehensive evaluation. Book a visit to discuss your symptoms and receive expert neurological assessment.

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References:

1. Edlow JA, Carpenter C, Akhter M, et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department 3 (GRACE-3): Acute Dizziness and Vertigo in the Emergency Department. Academic Emergency Medicine. 2023;30(5):442-486.
2. Shah VP, Oliveira J E Silva L, Farah W, et al. Diagnostic Accuracy of the Physical Examination in Emergency Department Patients With Acute Vertigo or Dizziness: A Systematic Review and Meta-Analysis for GRACE-3. Academic Emergency Medicine. 2023;30(5):552-578.
3. Navi BB, Kamel H, Shah MP, et al. Rate and Predictors of Serious Neurologic Causes of Dizziness in the Emergency Department. Mayo Clinic Proceedings. 2012;87(11):1080-8.
4. Gerlier C, Hoarau M, Fels A, et al. Differentiating Central From Peripheral Causes of Acute Vertigo in an Emergency Setting With the HINTS, STANDING, and ABCD2 Tests: A Diagnostic Cohort Study. Academic Emergency Medicine. 2021;28(12):1368-1378.
5. Wang W, Zhang Y, Pan Q, et al. Central Nystagmus Plus ABCD Identifying Stroke in Acute Dizziness Presentations. Academic Emergency Medicine. 2021;28(10):1118-1123.
6. Basura GJ, Adams ME, Monfared A, et al. Clinical Practice Guideline: Ménière's Disease. Otolaryngology--Head and Neck Surgery. 2020;162(2_suppl):S1-S55.
7. Hunter BR, Wang AZ, Bucca AW, et al. Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo: A Systematic Review and Meta-analysis. JAMA Neurology. 2022;79(9):846-855.
8. Edlow JA, Carpenter C, Akhter M, et al. Guidelines for Reasonable and Appropriate Care in the Emergency Department 3 (GRACE-3): Acute Dizziness and Vertigo in the Emergency Department. Academic Emergency Medicine. 2023;30(5):442-486.
9. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology--Head and Neck Surgery. 2017;156(3_suppl):S1-S47.
10. Baloh RW. Clinical Practice. Vestibular Neuritis. The New England Journal of Medicine. 2003;348(11):1027-32.
11. Hain TC, Uddin M. Pharmacological Treatment of Vertigo. CNS Drugs. 2003;17(2):85-100.

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