About Dizziness

Dizziness is a common presenting symptom that may include vertigo (an illusion of motion of the individual or their surroundings), lightheadedness or presyncope, imbalance, poor coordination, or a combination of these sensations. The term “dizziness” is descriptive rather than diagnostic and encompasses a wide range of underlying causes.

While most causes are benign and self-limiting, dizziness may also be an early manifestation of serious neurological, cardiovascular, or vascular conditions. Careful assessment is therefore essential to differentiate benign peripheral causes from central or systemic pathology and to identify individuals requiring urgent medical evaluation.

This care pathway focuses on the assessment and conservative management of benign peripheral causes of dizziness, with particular emphasis on benign paroxysmal positional vertigo (BPPV), one of the most common and treatable causes of vertigo encountered in musculoskeletal and primary care settings. Despite the term “benign,” BPPV is associated with increased fall risk, impaired activities of daily living, work limitations, and reduced quality of life, underscoring the importance of timely recognition and management.

This pathway provides clinicians with a structured approach to evaluating patients presenting with dizziness, supports differentiation of BPPV from other causes, outlines evidence-based conservative management of confirmed BPPV, and guides appropriate referral or escalation of care when indicated.

About CCG Care Pathways

Purpose

CCG care pathways provide structured, evidence-based guidance for clinicians delivering conservative, non-operative care for common musculoskeletal conditions. They outline key steps of the clinical encounter, support safe and appropriate decision-making, and assist with referral or co-management when indicated. Pathways are designed as practical, user-friendly tools that complement, not replace, clinical judgment.

Development

Pathways are developed using the best available evidence from high-quality clinical practice guidelines when they exist, and from systematic reviews and expert consensus when guideline evidence is limited or evolving. Content is reviewed periodically to reflect emerging research and current best practices. Input from clinicians, educators, and researchers helps ensure pathways remain relevant, aligned with real-world practice, and responsive to user needs.

Principles of Conservative Care

Musculoskeletal conditions are multifactorial and often influenced by physical, psychological, social, and environmental factors. As such, there is no one-size-fits-all approach to care. Effective management should be ethical, evidence-informed, transparent, flexible, and tailored to individual needs. Shared decision-making ensures care aligns with patient goals and values. Ongoing monitoring and outcome assessment support a person-centred approach and enable timely adjustments to care plans. Care may be delivered in-person, virtually, or through hybrid models, guided by patient preference, access, and clinical judgment.

Disclaimer

CCG care pathways are intended to support, not substitute for, professional clinical decision-making or the advice of a qualified healthcare provider. Recommendations are evidence-informed and presented in simplified, accessible language to support clinical understanding and application. Terms used throughout are not intended as formal diagnostic or billing terminology, nor are pathways prescriptive, authoritative, or regulatory.

Providers are expected to apply their clinical expertise and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems (e.g., ICD-10-CA), scope-of-practice documents, continuing professional education resources, and peer-reviewed literature. Pathways may not apply to every clinical scenario and should always be interpreted in the context of individual patient needs.

Benign Peripheral Causes of Dizziness Pathway

1. Record Keeping

Accurate, timely, and comprehensive documentation is an essential component of high-quality, evidence-based care. Clinical records must clearly reflect patient interactions, clinical reasoning, and progress over time, and should meet all jurisdictional regulatory standards.

Providers are encouraged to use a structured note format, such as the SOAP framework, to support consistency, clarity, and continuity of care.

Subjective: Document the patient’s reported symptoms, concerns, functional changes, contextual factors (e.g., psychosocial or environmental influences), and responses to prior care.

Objective: Record measurable or observable findings, including physical examination results, relevant diagnostic tests, functional assessments, and any clinically significant changes.

Assessment: Provide the clinical interpretation of findings, including diagnostic impressions or updates, identification of key risk factors or modifiers, and evaluation of the patient’s status or progression.

Plan: Outline the management strategy, including treatments delivered, modifications made, patient education and self-management recommendations, referrals, co-management decisions, and planned follow-up.

Documentation should be completed contemporaneously and maintained in accordance with regulatory requirements for privacy, security, and record retention. High-quality records support patient safety, facilitate interprofessional communication, enable shared decision-making, and promote continuity and accountability in care.

2. Informed Consent

Definition: A process where the patient voluntarily agrees to proposed healthcare interventions after receiving adequate information on the nature, benefits, risks, and alternatives.
Key Aspects:
- Prior to interaction: Obtain consent before any diagnostic testing or treatment. Ensure the patient understands the planned examinations, treatments, expected outcomes, and is given the opportunity to ask questions.
- Voluntarily and specific: Consent must be given willingly, without coercion, and pertain to the specific condition and proposed treatment. The patient should also understand that they can withdraw consent at any time.
- Transparent process: Consent must be obtained honestly, with a clear explanation of the condition and proposed interventions. Consent is not a one-time event, and involves ongoing discussions with the patient.
- Patient understanding and agreement:
  - Diagnosis/prognosis: Explain findings clearly, using understandable language and visuals if needed.
  - Treatment plan: Outline recommended treatments and how they align with patient goals. Discuss benefits, risks, and alternatives.
  - Questions: Encourage questions and confirm understanding (e.g., “teach-back”).
- Documentation: Record the consent process, including information provided, patient questions, and explicit consent given.

3. Health History

Apply cultural awareness and trauma-informed care principles.
Sociodemographic: Age (BPPV most commonly presents between ages 40- 60), sex, gender, race/ethnicity.
Main complaint: Ask the individual to describe the dizziness (e.g. lightheadedness/presyncope, disequilibrium, or true vertigo). Clarify timing, frequency, duration, and triggers. In BPPV, symptoms, symptoms typically consist of brief, discrete episodes of vertigo (≤1 minute) triggered by changes in head position (e.g., rolling in bed, looking up, bending forward). Individuals often report avoidance of triggering movements.
Associated complaints: Document pain characteristics where present, including location (e.g. head, neck, jaw), radiation, frequency, intensity, character, aggravating/relieving factors. Ask about associated otologic or neurologic symptoms (e.g., hearing loss, tinnitus, diplopia, imbalance, nausea, visual disturbance).
Impact on function: Assess history of falls or near-falls, imbalance, movement avoidance, and interference with daily activities, work, caregiving roles, or driving.
Body systems review: Cardiovascular factors (e.g., hypertension, arrhythmia, syncope), neurological conditions (e.g., migraine, prior stroke or TIA), vestibular disorders, recent infections, trauma (especially head or neck injury).
Health, lifestyle, family, social, and occupational history: Past medical conditions, recent illnesses, hospitalizations, or surgeries; medications (including antihypertensives, vestibular suppressants, psychoactive drugs); history of injuries or head trauma. Lifestyle: diet, physical activity, sleep habits, alcohol/substance use. Family history of vestibular, neurological, or cardiovascular disorders; occupational or environmental exposures.
Social determinants of health: Falls risk at home (stairs, rugs, poor lighting); ability to mobilize safely; access to care; transportation; financial barriers; family or social supports; caregiver responsibilities; work environment, demands, and flexibility.
Previous treatments and responses: Effectiveness of prior interventions and any adverse events.
Beliefs and expectations: Understanding of their condition. Treatment, recovery, and prognosis expectations.
Red, yellow, and orange flags: Screen for these systematically.

Outcomes Assessments:

Function and Participation: Impact of dizziness on daily activities (PSFS, WHODAS).
Quality of Life: SF-12.
Falls and near-falls: Frequency (e.g., past week/month)
Individual Goals: SMART goal setting: Specific, Measurable, Achievable, Relevant, Timely.
Patient Feedback: Experience and satisfaction with care.

4. Red Flags and Differential Diagnosis Requiring Medical Attention

Clinicians must remain alert to features suggesting central, vascular, cardiac, or other serious causes of dizziness. When red flags are identified, conservative care should be deferred and timely medical referral initiated.

ACTION: Refer immediately to emergency care:

Intracranial/brain pathology: Sudden severe (“thunderclap”) headache or progressively worsening headache (with or without neck pain), dizziness, visual disturbance, nausea/vomiting, focal neurological signs, cranial nerve abnormalities, papilledema, or features of raised intracranial pressure (e.g., headache worse in the morning, with coughing, straining, or forward bending).
Vertebral/carotid artery dissection: Sudden onset severe neck pain or “worst headache ever”, dizziness, diplopia, dysarthria, dysphagia, ataxia, facial numbness or droop, unilateral sensory/motor deficits, slurred speech, loss of consciousness, nausea, or central ocular signs (e.g., vertical or direction-changing gaze-evoked nystagmus).
Cardiac: Chest pain, palpitations, shortness of breath, exertional dizziness, syncope or near-syncope.
Head or cervical spine trauma:
Apply validated decision rules where applicable:
- Canadian CT Head Rule (adults following head injury): GCS <15 at 2 hours, suspected skull fracture, signs of basal fracture (leaking fluid from ears/nose, raccoon eyes, Battle’s sign), vomiting ≥2 episodes, age ≥65 years.
- Canadian C-Spine Rule (cervical trauma): Age ≥65 years, dangerous mechanism, weakness/tingling in extremities, inability to rotate neck 45° left/right, midline tenderness.
- PECARN Minor Head Injury/Trauma Rule (children <2 years): GCS score <15, altered mental status, palpable skull fracture, non-frontal scalp hematoma, loss of consciousness ≥5 seconds, severe mechanism of injury (e.g., fall >3 feet), not acting normally according to the parent.
Additional neurological red flags: Severe or persistent vertigo, ataxia, dysmetria, focal neurological deficits.

ACTION: Refer to appropriate medical provider:

Progressive or unexplained hearing loss: Associated with Ménière’s disease or CN VIII lesions.
Suspected central causes of vertigo: e.g., symptoms suggestive of cerebellar or brainstem involvement, or findings inconsistent with a benign peripheral pattern
Unexplained persistent or atypical dizziness: Dizziness that does not fit a peripheral pattern (e.g., not positionally triggered, lack fatigability, or is continuous without clear provocation).
Orthostatic hypotension: Persistent or symptomatic blood pressure drops contributing to falls or functional impairment despite initial management.

5. Orange Flags: Symptoms of Psychiatric Disorders Requiring Referral

Clinicians should promptly address symptoms of potential mental health disorders to prevent harm through appropriate and timely referrals.

ACTION: Refer for immediate care (emergency department, medical/mental health provider):

Suicidal ideation: Thoughts, plans, or statements about suicide or feelings of hopelessness.
Severe, acute symptoms: Acute psychological distress, such as psychosis, severe panic.
Ideation of harm: Intent or plans to self-harm, commit violence, or harm others.

ACTION: Refer to appropriate medical/mental health provider:

Persistent, non-urgent symptoms: Symptoms affecting daily functioning (e.g., low mood, anxiety, sleep disturbances, social withdrawal, substance use).

ACTION: Co-management by non-medical/mental health providers:

Triage: Ensure primary management by medical/psychiatric providers.
Musculoskeletal (MSK) treatment: Manage MSK conditions related to or comorbid with psychological disorders.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation without implying a diagnosis. Tools include:
- PHQ-9 (depressive symptoms)
- GAD-7 (anxiety symptoms)
- FABQ (fear related to physical activity/work)
- PCS (catastrophic thoughts)
- ORT (opioid risk)

6. Yellow Flags: Psychosocial Factors that May Delay Recovery

Non-health barriers can delay recovery; early identification and intervention can enhance outcomes.

Factors:

Individual: Worry, fear of movement, low recovery expectations, limited self-efficacy, reliance on passive treatments, activity avoidance.
Social: Lack of family/social support, limited connections.
Socioeconomic: Employment status, financial stress, litigation/compensation.
Environmental/cultural: Social inequality, unsafe/unsupportive environments.
Life events: Major transitions (e.g., divorce, job loss), chronic stressors (e.g., caregiving).
Work/school: High stress, poor work-life balance, limited accommodations for injury/illness.

ACTION: Co-management by non-medical/mental health providers:

Education & self-care: Provide resources for (e.g., stress management, coping strategies, graded activity).
Monitor & coordinate: Regularly assess psychosocial challenges; refer to medical/mental health provider if persistent.
Screening tools: Selectively use tools to monitor symptoms and severity, guide care, and support escalation (aligned with Orange Flag guidance), without implying a diagnosis. Tools include:
- PHQ-9 (depressive symptoms)
- GAD-7 (anxiety symptoms)
- FABQ (fear related to physical activity/work)
- PCS (catastrophic thoughts)
- ORT (opioid risk)

7. Physical Examination Considerations

The physical examination should be targeted and hypothesis-driven, guided by the history to help differentiate benign peripheral causes from central or systemic pathology.

Observation: Observe for spontaneous or gaze-evoked nystagmus, noting direction and behavior. Direction-changing or vertical nystagmus, marked disequilibrium, poor coordination, or abnormal gait may suggest central pathology and warrant referral. Observe general balance, postural control, and safety during movement.
Neurological screening
- Cranial nerves
- Limb coordination, gross motor function
- Cerebellar function (e.g. finger-nose, heel-shin)
- HINTS testing (Head-Impulse, Nystagmus, Test of Skew) may be used by clinicians with appropriate training in individuals presenting with continuous vertigo and spontaneous nystagmus (acute vestibular syndrome) to help differentiate peripheral from central causes. It is not indicated for episodic, positionally triggered dizziness such as typical BPPV.
Orthostatic blood pressure: Assess blood pressure and heart rate with positional change when lightheadedness, presyncope, or falls are reported, or when cardiovascular contributors are suspected.
Special/Orthopedic Tests: Perform positional testing when the history is compatible with BPPV. (Bhattacharyya, 2017; Edlow, 2023)
- Dix-Hallpike: Used to assess posterior semicircular canal BPPV. Assist the individual from sitting to supine with the head turned 45° and extended 20°, affected ear down. Observe for characteristic torsional-vertical nystagmus with brief latency and fatigability (typically <60 seconds). Repeat on the opposite side if the initial test is negative.
- Supine-roll test: Used when the history suggests BPPV but the Dix-Hallpike test is negative or produces horizontal nystagmus. From supine, patient rapidly rotates the head 90⁰ to each side while observing for horizontal nystagmus, to assess for horizontal canal involvement.
- Perform additional tests as clinically indicated.
Advanced Diagnostic Imaging: (Bhattacharyya, 2017, Edlow, 2023)
- Not indicated when the presentation is consistent with BPPV, positional testing is positive, and no red flags are present. Imaging may be warranted when findings are atypical, inconclusive, or suggestive of central or non-benign pathology.

8. Clinical Amenable to Conservative Care

This care pathway applies to individuals whose history and examination are consistent with benign peripheral causes of dizziness, most commonly benign paroxysmal positional vertigo (BPPV), and do not demonstrate red flags or features suggestive of central or systemic pathology.

Typical Presentation Consistent with BPPV (Bhattacharyya, 2017)

Individuals commonly report:

Brief, discrete, episodes of vertigo, typically lasting ≤1 minute
Symptoms triggered by specific changes in head position, such as rolling in bed, looking up, bending forward, or lying back
A predictable pattern of symptom provocation, often leading to avoidance of triggering movements
Associated nausea or imbalance during episodes, with relative symptom resolution between episodes

Between episodes, individuals are often neurologically intact, though they may report residual unsteadiness or reduced confidence with movement.

Examination Features Supporting a Benign Peripheral Pattern

Positionally induced nystagmus observed during positional testing, with characteristics consistent with peripheral vestibular involvement (e.g., latency, fatigability, direction consistent with the involved semicircular canal)
Absence of focal neurological deficits, central ocular motor signs, or concerning systemic features
Findings that align with the individual’s reported symptom triggers and temporal pattern

Functional Impact

Even when benign, BPPV can result in:

Increased fall risk or near-falls
Avoidance of movement or activity
Reduced participation in daily activities, work, or caregiving roles
Heightened anxiety related to symptom unpredictability

These functional consequences support the role of timely conservative management, even when symptoms are episodic or intermittent.

9. Conservative Treatment Considerations for Dizziness (BPPV)

Conservative management should be guided by clinical presentation, positional testing findings, patient preferences, and safety considerations. The primary goal is to resolve vertigo, reduce fall risk, and restore confidence with movement, while avoiding unnecessary investigations or prolonged symptoms.

Management is most effective when appropriate canalith repositioning procedures are delivered promptly and followed by education and activity guidance.

Education and Reassurance (Bhattacharyya 2017)

Education should include reassurance regarding the benign nature and favorable prognosis of BPPV, explanation of symptom mechanisms, and guidance on what to expect following treatment. Individuals should be informed that transient symptom provocation during treatment is common and expected.

Avoidance of unnecessary movement restriction should be encouraged. Routine activity limitation or prolonged postural restrictions are not recommended following repositioning procedures.

Canalith Repositioning Procedures (Bhattacharyya 2017, Edlow 2023, Thakur 2024)

Canalith repositioning procedures are the first-line treatment for confirmed BPPV.

Posterior canal BPPV:
The Epley maneuver (or equivalent posterior canal repositioning procedure) is recommended.
Horizontal canal BPPV:
Appropriate horizontal canal maneuvers (e.g., Lempert/barbecue roll or modified variants) may be used based on clinical findings.

Repositioning procedures may be repeated within or across visits as clinically indicated. Selection of maneuver should be based on canal involvement identified during positional testing.

Post-Treatment Considerations

Following repositioning:

Patients may experience temporary imbalance, lightheadedness, or mild residual symptoms
Formal postural restrictions (e.g., sleeping upright) are not routinely required
Follow-up should focus on symptom resolution and functional recovery

Vestibular Rehabilitation and Exercise

Vestibular rehabilitation exercises (e.g., Brandt-Daroff, balance training, head-trunk-eye movements) are not routinely required for isolated BPPV once vertigo resolves. They may be considered when:

Residual imbalance or motion sensitivity persists
There is fear of movement or activity avoidance
BPPV recurs or coexists with other vestibular conditions

Exercises should be graded, functional, and confidence-building, rather than symptom-provoking for their own sake.

Medications (Bhattacharyya 2017)

Vestibular suppressants (e.g., antihistamines, benzodiazepines) are not recommended for routine management of BPPV.

Recurrent or Refractory Symptoms

For individuals with recurrent BPPV:

Repeat canalith repositioning remains appropriate
Education on recurrence risk and early symptom recognition is important
Referral may be considered if symptoms are atypical, persist despite appropriate maneuvers, or suggest alternative pathology

10. Risk and Prognostic Factors for Dizziness (BPPV)

Risk Factors: (Chen, 2020; Yeo, 2024)

BPPV is more common with increasing age and is among the most frequent causes of vertigo in adults. Factors associated with increased risk of BPPV include:

Older age, with peak incidence in middle-aged and older adults
History of head trauma, including minor head injury
Prior episode of BPPV, which is the strongest predictor of recurrence
Prolonged bed rest or immobilization
Inner ear disorders, including vestibular neuritis or Ménière’s disease
Migraine, which is associated with higher incidence and recurrence
Osteoporosis or low bone mineral density, particularly in postmenopausal women
Anxiety

Prognosis:

The prognosis for BPPV is highly favorable. Most individuals experience rapid symptom resolution following appropriate canalith repositioning procedures, often within one or a small number of treatment sessions.

Even without treatment, spontaneous resolution can occur; however, untreated BPPV is associated with increased fall risk, activity restriction, and reduced quality of life, supporting early intervention.

Recurrence and Persistence:

Recurrence is common, with reported recurrence rates ranging from approximately 15–50% over several years, depending on population and follow-up duration.
Recurrence risk is higher in individuals with prior BPPV, migraine, head trauma, or metabolic bone disease.
A small subset of individuals may report residual dizziness or imbalance after resolution of positional vertigo, which may benefit from reassurance, graded activity, or vestibular rehabilitation.

Negative Prognostic Indicators for Recurrence or Persistence (Bhattacharyya, 2017):

Atypical symptom patterns or examination findings inconsistent with peripheral BPPV
Incomplete or transient response to appropriately performed canalith repositioning
Comorbid central nervous system disorders
Comorbid mobility impairments affecting balance or transfers
Comorbid conditions associated with increased fall risk
Lack of adequate home or social support, particularly in individuals at risk of falls
Fear of movement or activity avoidance, which may prolong functional limitation despite resolution of vertigo

11. Ongoing Follow-Up (Bhattacharyya, 2017):

Canalith repositioning procedures may be repeated until the individual is symptom-free for 24 hours.
Individuals should be reassessed within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms.
Individuals with persistent BPPV symptoms or suspected underlying peripheral vestibular or central nervous system disorders should undergo further assessment.

12. Criteria for Discharge

Resolution of positional vertigo.
Tolerance of daily activities and functional movements without dizziness or fear of falling
Educated on self-management strategies and when to seek care if symptoms recur.
Referral is indicated if symptoms change, worsen, or do not resolve.

Dizziness (BPPV)