First, remain calm. If you have a family member or friend nearby, make sure they are with you now. If this is a new problem for you, the key question is whether you should call 911 and go immediately to the emergency room.

If you are dizzy right now and have any of the following neurological symptoms along with your dizziness or vertigo, call 911 immediately:

• New confusion or trouble speaking or understanding speech
• New slurred speech or hoarseness of voice
• New numbness or weakness of the face, arm, or leg
• New clumsiness or tremor (shaking) of the arms or legs
• New trouble seeing out of one or both eyes, or to one side
• New double vision or inability to move one or both eyes
• New unequal pupils or drooping eyelid on one side
• New inability to stand even when holding onto something firm
• Sudden severe vomiting with no known cause
• Sudden severe headache or neck pain with no known cause

Dizziness, Stroke and TIA

Even if you don't have any of the symptoms above, you could still be having a stroke or have suffered a recent pre-stroke (transient ischemic attack or TIA). A stroke or TIA is more likely if you are older or have known stroke risk factors (such as smoking, high blood pressure, high cholesterol, diabetes, atrial fibrillation, sickle cell disease, or a personal or family history of stroke or heart attacks).

But even young people with none of these traditional stroke risk factors can still suffer a stroke. Furthermore, there are dangerous heart conditions (heart attack or cardiac arrhythmia) that can also cause dizziness or vertigo. If you do not already know the cause of your new dizziness or vertigo, call your doctor right away or go to the emergency room to be assessed.

The only definite way to know you have not suffered a stroke or TIA is to be sure that you know that your dizziness or vertigo is due to something less serious. The most common conditions are benign paroxysmal positional vertigo (BPPV), vestibular migraine, Menière’s disease and vestibular neuritis/labyrinthitis. Unfortunately, each of these conditions can produce symptoms very similar to those of stroke or TIA, so careful attention to symptom details is required. 

Benign Paroxysmal Positional Vertigo (BPPV)

If the dizziness or vertigo symptoms follow any of the following patterns, the cause is likely BPPV: (1) symptoms are intermittent; (2) symptoms occur only when the head is tipped or moved in a particular direction (especially when rolling over in bed to one side); (3) symptoms last for less than a minute after the head position change as long as the head is held still and (4) there is no vomiting, hearing loss or neurological symptoms.

Although rare exceptions do occur, people with these symptom patterns usually do not have strokes. People experiencing these symptoms should  contact their primary physician for advice.

Vestibular Migraine and Menière’s Disease

If the dizziness or vertigo comes in episodes that last for minutes to hours, it could be due to vestibular migraine (usually without hearing symptoms) or Menière’s disease (usually with hearing symptoms), but it also can be the result of a pre-stroke (transient ischemic attack, or TIA). Those who have had such symptoms repeatedly over many years usually do not have TIA, but when the first episode occurs, it is advisable to seek medical care right away to assess your immediate risk for stroke.

If there are obvious neurological symptoms (described in detail above), call 911 or proceed immediately to the emergency room. If there are no obvious neurological symptoms, it is reasonable for patients to contact their primary physician for advice.

Vestibular Neuritis and Labyrinthitis

If the dizziness or vertigo is new, severe and persists for hours to days; has not stopped; and is associated with vomiting and trouble walking, it could be due to vestibular neuritis (usually without hearing symptoms) or labyrinthitis (usually with hearing symptoms). This symptom complex is identical to the symptoms seen with strokes in the balance part of the brain (brainstem or cerebellum), and it is impossible to exclude stroke without careful examination of the patient’s eye movements.

Even without neurological symptoms, patients with this symptom complex should generally call 911 or proceed directly to the emergency room to get immediate help. There, patients with this acute vestibular syndrome should expect the examiner to carefully inspect their eyes, including performing a test with a rapid head turn to either side while the patient looks straight ahead (head impulse test). This test can be performed with or without a special diagnostic device (quantitative video-oculography) sometimes referred to as “stroke goggles.”

When performed properly and combined with two other eye exams (together called “HINTS”), this exam can confirm vestibular neuritis rather than stroke. This approach has been shown to be more accurate than brain imaging in several scientific studies. Although it is common for patients to undergo CT scan of the brain in this setting, CT is generally unhelpful and risks radiation exposure. If neuroimaging is required, this should generally be by MRI scan of the brain.