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 is a knowledge translation resource of the Canadian Chiropractic Association. Its care pathways help chiropractors and other clinicians organize conservative care for musculoskeletal conditions. Each pathway outlines the main steps of the clinical encounter and supports decisions about assessment, care, monitoring, referral, co-management, and discharge. The pathways provide a structured approach to care, not a fixed prescription.

Development

Pathways draw on relevant clinical practice guidelines, systematic reviews, peer-reviewed literature, and safety or professional sources. These sources inform, but do not determine, pathway content. Their findings reflect the questions, populations, outcomes, methods, and judgments used and may not apply to every person. Condition-specific sources are identified by author or organization and year, with full citations in one reference list at the end of the pathway.

Principles of Care

Musculoskeletal conditions are shaped by physical, psychological, social, cultural, and environmental factors, so no single approach fits everyone. Good care is ethical, evidence-informed, person-centred, culturally responsive, and tailored to the patient’s goals, preferences, circumstances, and response. Shared decision-making and informed consent guide care. Education, active rehabilitation, and self-management support recovery, functioning, participation, and long-term health. Regular reassessment shows whether the plan is helping and when to continue, adapt, stop, refer, co-manage, or discharge.populations.

Pathway Flow at a Glance

The pathway follows a recurring clinical cycle: understand the person and their goals; screen for safety and referral needs; develop a working clinical profile; agree on a plan and relevant outcomes; provide care; reassess response and safety; and continue, adapt, stop, refer, co-manage, or discharge as appropriate.

Disclaimer

CCG care pathways support professional clinical judgment; they do not replace it or the advice of a qualified provider. They are not prescriptive, authoritative, or regulatory and are not intended for diagnosis or billing. Clinicians remain responsible for practicing within their competence and scope, meeting applicable legal and regulatory requirements, obtaining informed consent, recognizing emergencies, and arranging referral or co-management when needed.

Benign Peripheral Causes of Dizziness Pathway

1. Record Keeping

Accurate, timely, and sufficiently detailed documentation supports safe, high-quality care. The record should reflect clinically relevant patient interactions, clinical reasoning, decisions, care provided, and progress over time. Documentation should meet the legal, regulatory, privacy, retention, and organizational requirements that apply where the clinician practices. A structured format, such as SOAP, may support consistency, clarity, and continuity and can be adapted to the encounter and practice setting.

Subjective: Record the patient’s concerns, symptoms, functioning and participation, goals, preferences, relevant history and context, and response or adverse effects from previous care.

Objective: Record relevant examination findings, outcome measures, diagnostic test results when available, and clinically important changes.

Assessment: Record the clinical interpretation of findings, working diagnosis or clinical profile, differential and safety considerations, relevant risk factors or modifiers, and the patient’s progress or response.

Plan: Record care provided or proposed, education and self-management, consent and patient decisions, changes to the plan, agreed outcomes and reassessment point, referrals or co-management, follow-up, and discharge planning.

Document at the time of the encounter or as soon as practicable. Corrections and additions should preserve the integrity of the record. Clear records support patient safety, shared decision-making, communication, continuity, and accountability.

2. Informed Consent

Definition: A continuing process in which a capable patient, or an authorized substitute decision-maker when required, voluntarily agrees to a proposed examination or intervention after receiving and understanding the information needed to make an informed choice.
Key Aspects:
- Prior to interaction: Obtain consent before beginning an examination, procedure, or treatment, except where applicable law permits otherwise. Explain what is proposed and why. Revisit consent when the plan or material information changes.
- Voluntarily and specific: must be voluntary and specific to the proposed care. Consider the patient’s capacity for the decision at the time it is required and follow applicable requirements for substitute decision-making when the patient lacks capacity. The patient may ask questions, refuse, place limits on, or withdraw consent.
- Transparent process: Use honest, plain, and accessible communication. Offer interpretation or other communication support when needed and consider language, culture, health literacy, disability, and prior trauma. Written or digital information may support but does not replace discussion.
- Patient understanding and agreement:
  - Diagnosis/prognosis: Explain relevant findings, the clinical impression or working diagnosis, important uncertainty, and the expected course in understandable language.
  - Treatment plan: Discuss the nature and purpose of proposed care, expected benefits, material risks and side effects, burdens, reasonable alternatives, the option of no intervention, and the likely consequences of accepting or declining.
  - Questions: Invite questions, explore goals and preferences, allow appropriate time for a decision, and confirm understanding, for example using teach-back.
- Documentation: Record the consent discussion and decision, including material information provided, questions, capacity or substitute decision-maker where relevant, consent, refusal, limits or withdrawal, and any need to revisit consent. Follow documentation requirements applicable to the jurisdiction and practice setting.

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

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

Suicide or self-harm thoughts: thoughts without immediate danger.
Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

6. Yellow Flags: Factors that May Affect Recovery or Participation

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

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)