The diagnosis and management of vertigo remains a challenge for clinicians, including general neurology. In recent years there have been advances in the understanding of established vestibular syndromes, and the development of treatments for existing vestibular diagnoses. In this ‘update’ I will review how our understanding of previously “unexplained” dizziness in the elderly is changing, explore novel insights into the pathophysiology of vestibular migraine, and its relationship to the newly coined term ‘persistent postural perceptual dizziness’, and finally discuss how a simple bedside oculomotor assessment may help identify vestibular presentations of stroke.

The world of dizziness has experienced a dramatic change over the last 3 decades, as new treatable syndromes have been identified, and novel treatments developed for existing vestibular diagnoses. Despite such progress, many clinicians, including neurologists, admit to a lack of confidence in the diagnosis and management of the dizzy patient, leading to circuitous patient journeys, from one specialty to another. Most emergency and primary care ‘dizzy’ referrals in the UK are fielded to ENT surgeons, a departure from neuro towards otology, although it could be argued that vertigo is a neurological symptom, a cortically driven percept, irrespective of the causative insult.

One common challenge in the field is elderly patients reporting a vague sense of dizziness and imbalance, who as a result of normal audiovestibular testing, remain “unexplained”. I will review recent evidence suggesting possible mechanisms relating to small vessel disease that may contribute to this syndrome. Whilst new variants of benign paroxysmal positional vertigo (BPPV) have been recently described [1], the Epley and Semont treatment manoeuvres for the commonest type of BPPV are still not universally employed by neurologists [2], and BPPV remains under-diagnosed, and under-treated. The commonest differential diagnosis for BPPV is vestibular migraine, a condition that is increasingly recognised outside specialist centres, but remains under-diagnosed. Here, I review the most recent advances in vestibular migraine (VM) diagnosis and treatment. VM in turn is a common precursor to a more chronic form of dizziness recently renamed persistent postural perceptual dizziness (PPPD), and there has been a growth in the unravelling of the neurobiology of this disorder. Finally, vestibular neurology is rich in clinical bedside skills; indeed, an evaluation of eye movements may more precisely identify and localise a stroke than state-of-the-art imaging [3]. I describe and review the use and utility of the HINTS examination in stroke.