The research, published in the Journal of Emergency and Disaster Medicine, examined 96 adult encounters for acute peripheral vertigo at Rasool-e-Akram Hospital in Tehran between January and June 2024. Peripheral vertigo, in which the sensation of spinning originates in the inner ear rather than the brain, is most often caused by benign paroxysmal positional vertigo, vestibular neuritis, or Ménière’s disease. Yet because these same symptoms can occasionally signal a stroke, emergency clinicians face a diagnostic tightrope: they must rule out dangerous central causes while relieving distressing symptoms and keeping patients moving through a crowded department.

The research team, led by emergency medicine physicians and researchers affiliated with Iran University of Medical Sciences, conducted a cross-sectional review of patient charts, excluding anyone with a documented central cause of vertigo, incomplete management records, or a history of chronic vertigo. The cohort, with a mean age of 60.3 years and a striking 68.8 percent female majority, was analyzed for five vertigo-specific drugs commonly used in emergency settings: ondansetron, betahistine, promethazine, metoclopramide, and benzodiazepines such as diazepam. The primary outcome was length of stay, measured in minutes from documented arrival to physical departure from the department.

The headline result was stark. Patients who received three or more distinct vertigo medications stayed a median of 652 minutes, compared with 467.5 minutes for those given two or fewer drugs, a difference that held up under non-parametric statistical testing. In a multivariable linear regression adjusted for age, sex, consultation patterns, and self-discharge status, complex regimens were independently associated with an additional 180.9 minutes of department time, with a 95 percent confidence interval of 76.0 to 285.7 minutes and a p-value of 0.0009. The mean stay in the simple-regimen group was 528 minutes, while the complex-regimen group averaged 752.3 minutes, a gap of nearly four hours.

Drug-specific analyses sharpened the picture further. Benzodiazepines, the sedating class often deployed to dampen the anxiety and vestibular storm of acute vertigo, were strongly linked to longer stays, adding an estimated 356.2 minutes even after adjustment for regimen complexity and consultations. The authors suggest this may reflect the sedation burden such drugs impose, which typically mandates prolonged observation before patients can be safely discharged. Promethazine, by contrast, was independently associated with a shorter stay, reducing department time by an estimated 161.3 minutes, possibly because it achieves faster symptom control or because clinicians reserve it for more straightforward presentations. Ondansetron, betahistine, and metoclopramide showed no clear independent association, though the authors caution that small exposed groups and confounding by indication, in which sicker patients receive certain drugs, make these estimates imprecise.

Consultations emerged as the other major lever on throughput. Neurology was the most frequently requested specialty, consulted in 28.1 percent of encounters, followed by cardiology at 15.6 percent. More than half of visits required no consultation at all, but 40.6 percent involved one and 7.3 percent involved two. In the adjusted model, neurology consultation added an estimated 163.9 minutes, while internal medicine and ear, nose, and throat consultations were associated with even larger increases of 501.3 and 476.0 minutes respectively, all statistically significant. The authors interpret these large effects not as evidence that the consultations themselves are wasteful, but as a signal that their involvement flags clinically challenging presentations, such as cardiovascular comorbidity or overlapping otologic disease, that demand additional diagnostic workup.

The prescribing patterns documented in the study reveal a clear hierarchy of practice. Ondansetron, a serotonin-receptor antagonist used to control vertigo-related nausea, was the first drug ordered for nearly half the cohort and was administered at some point to more than 70 percent of patients, consistent with international guideline support for this class. When a second-line agent was needed, betahistine topped the list, reflecting its long-standing track record in peripheral vestibular disease. Diazepam appeared in a smaller number of regimens, hinting at clinicians’ awareness of the anxiety that frequently accompanies acute vertigo, a dimension emphasized in the psychosocial literature on vestibular disorders.

The authors are careful to frame their findings as hypothesis-generating rather than prescriptive. Because the study lacked standardized measures of vertigo severity or clinical acuity at arrival, it is entirely possible that patients who appeared more unwell both received more medications and required longer observation, meaning residual confounding by illness severity may partly explain the association between regimen complexity and longer stays. The single-center design, the absence of data on time to symptom relief, functional outcomes such as safe ambulation at discharge, and unplanned return visits, and the inability to analyze non-pharmacologic interventions like canalith repositioning maneuvers all constrain the conclusions. Rare consultation types produced wide confidence intervals that larger samples would need to tighten.

Even so, the operational message resonates with a broader body of evidence linking polypharmacy and regimen complexity to slower hospital throughput in other acute conditions, from bronchiectasis to sedation-heavy critical care. The findings align with expert recommendations favoring stepwise pharmacotherapy, in which drugs are added sequentially as needed, rather than simultaneous multi-drug administration from the outset. They also echo prior reports that specialty input, while essential when central causes are suspected, can inadvertently lengthen emergency department stays when requested routinely rather than selectively for peripheral vertigo.

The study’s authors propose that emphasizing focused bedside assessment, tools such as the head-impulse, nystagmus, test-of-skew examination, stepwise rather than simultaneous drug therapy, and judicious specialty consultation could improve both the quality and the pace of vertigo care. Prospective, multi-center interventional studies will be needed to determine whether pathways built on these principles can safely shorten emergency department stays without compromising diagnostic safety, particularly given the stakes of missing a stroke masquerading as benign dizziness. For now, the study offers emergency departments a concrete, testable target: fewer drugs, chosen deliberately, may be the fastest route to getting dizzy patients back on their feet and out the door.

Subject of Research: The association between pharmacological treatment complexity, specialty consultations, and emergency department length of stay in adults with acute peripheral vertigo.

Article Title: Therapeutic approaches and their association with hospitalization duration in patients with peripheral vertigo presenting to the emergency department

Article References: Therapeutic approaches and their association with hospitalization duration in patients with peripheral vertigo presenting to the emergency department. (n.d.). https://doi.org/10.1007/s44467-025-00007-4

Image Credits: AI Generated

DOI: 10.1007/s44467-025-00007-4

Keywords: peripheral vertigo, emergency department, length of stay, polypharmacy, benzodiazepines, promethazine, betahistine, ondansetron, neurology consultation, vestibular disorders, regimen complexity, emergency medicine

The study, led by Huseyin Nezih Ozdemir, Iryna Klopotovska and Diego Kaski of the SENSE Research Unit in UCL’s Department of Clinical and Movement Neurosciences, was conducted at the National Hospital for Neurology and Neurosurgery in London between April 2025 and April 2026. Consecutive patients aged 18 and over arriving at the dizziness clinic underwent a structured ten-question interview before their clinical consultation. Crucially, the interviewer recorded answers about symptom timing, triggers, avoidance behaviours and behavioural responses before any diagnosis had been established. The final diagnoses were then made independently by a vestibular neurologist who was blinded to the interview responses, using established criteria from the Bárány Society and the International Classification of Headache Disorders. This design ensured that the behavioural data could not be contaminated by knowledge of the diagnosis.

The cohort of 109 patients had a mean age of 55.3 years, and 71.5 percent were female. Thirty-three patients were diagnosed with vestibular migraine, thirty-three with persistent postural-perceptual dizziness, fourteen with benign paroxysmal positional vertigo and fifteen with orthostatic dizziness. Smaller groups included patients with central structural disorders such as posterior circulation stroke and other peripheral vestibular conditions including bilateral vestibular loss. When the researchers applied logistic regression to the interview data, four clear behavioural profiles emerged, each mapping closely onto the known biology of the underlying disorder.

The strongest single predictor belonged to vestibular migraine. Patients who reported that reading while travelling as a passenger in a vehicle brought on their dizziness were more than twenty times more likely to have vestibular migraine than any other diagnosis, with an odds ratio of 20.99. This finding fits with the idea that vestibular migraine reflects a heightened vulnerability to sensory conflict, the discordance between visual motion signals and vestibular input that occurs when the eyes track a page while the inner ear registers the movement of a car. It also builds on earlier work from the same group showing that motion sickness while reading in a moving car is highly predictive of the condition. For patients with persistent postural-perceptual dizziness, visually stimulating environments such as crowded, busy or visually complex settings were the strongest precipitating factor, carrying an odds ratio of 12.45, consistent with the disorder’s characteristic over-reliance on visual cues for spatial orientation.

The two remaining diagnoses produced equally distinctive patterns. For benign paroxysmal positional vertigo, head movements and positional changes were the dominant trigger, with an odds ratio of 11.51, exactly what would be expected from the abnormal movement of displaced calcium carbonate crystals, or otoconia, within the semicircular canals. Patients with orthostatic dizziness, by contrast, pointed to standing up quickly as their principal trigger, reflecting the transient drop in cerebral blood flow that occurs during orthostatic stress. In each case, the reported precipitant was not an arbitrary preference but a direct behavioural echo of the underlying mechanism: sensory conflict in vestibular migraine, visual dependence in persistent postural-perceptual dizziness, otoconial displacement in positional vertigo and cerebral hypoperfusion in orthostatic dizziness.

Avoidance behaviours proved just as diagnostic as triggers. Patients with vestibular migraine disproportionately avoided bright or noisy environments and sought refuge by resting in dark, quiet rooms, mirroring the visual and auditory hypersensitivity that characterises migraine more broadly. Those with persistent postural-perceptual dizziness avoided visually busy places such as supermarkets, crowded streets or scrolling screens, and notably reported trying to maintain their activity despite the symptoms, an effort to push through the persistent, physically non-disabling dizziness that defines the condition. Patients with benign paroxysmal positional vertigo reported deliberately avoiding quick head movements and staying still during attacks, an understandable strategy to prevent the violent, brief episodes of rotational vertigo that position changes provoke. Orthostatic dizziness patients avoided sudden standing and tended to sit or lie down slowly, a sensible countermeasure against orthostatic intolerance, although this particular association did not reach statistical significance, likely because of the smaller size of that subgroup.

Temporal patterns added a further layer of discrimination. Episodic dizziness was significantly associated with vestibular migraine, while patients with persistent postural-perceptual dizziness were far more likely to report continuous dizziness lasting days or longer, in keeping with the chronic nature of that disorder. Patients with benign paroxysmal positional vertigo characteristically reported brief episodes lasting seconds to minutes, matching its paroxysmal presentation. Although patients with positional vertigo and orthostatic dizziness tended to describe dizziness that comes and goes, these associations did not reach statistical significance, a limitation the authors attribute to the relatively small numbers in those diagnostic groups.

The clinical implications of the work are considerable. Because neuroimaging has limited utility in most cases of dizziness and definitive tests are lacking for many vestibular syndromes, diagnosis rests heavily on history taking, and patients’ descriptions of symptom quality are notoriously imprecise. Structured questions about avoidance and coping could capture dimensions of the patient’s experience that conventional symptom questions miss. Asking simply whether a patient avoids supermarkets, refrains from turning their head quickly, or retreats to a dark room when dizzy may sharpen diagnostic accuracy, shorten the long delays many patients experience before correct treatment, and potentially prevent progression to chronic dizziness. Beyond diagnosis, recognising these behaviours may help clinicians understand how the disorders impair daily and occupational functioning, since triggers such as bright environments or awkward head positions have been shown to interfere with work tasks and contribute to reduced productivity and absenteeism.

Perhaps the most intriguing aspect of the findings is that patients developed these behavioural signatures without any formal knowledge of disease mechanisms. The researchers argue that such adaptations arise intuitively through repeated symptom experience, which is precisely what makes them informative: they represent the body’s own experiment on the disorder, conducted over months or years. The behaviours therefore function as natural biomarkers, reflecting pathophysiology rather than clinical teaching. The authors also caution that avoidance behaviours can themselves contribute to disability, and identifying them may open the door to rehabilitation strategies that prevent deconditioning and fear-driven withdrawal from activity.

The study is not without limitations. The structured interview was not a validated instrument, several diagnostic subgroups were small, limiting statistical power for some response categories, and the single-centre design in a specialised London clinic may constrain generalisability. Larger cohorts will be needed to confirm the diagnostic value of these behavioural markers and to quantify their impact on patients’ functioning. Even so, the message is clear and potentially transformative for routine practice: when a patient says they feel dizzy, the clinician should ask not only what it feels like and when it happens, but what the patient does about it. The answers, this research suggests, may point directly to the diagnosis hiding behind one of medicine’s most vague and common complaints.

Subject of Research: Behavioural signatures as diagnostic clues in common vestibular disorders causing dizziness

Article Title: What patients do when they feel dizzy: behavioural signatures reveal diagnostic clues in common vestibular disorders

Article References: Ozdemir, H. N., Klopotovska, I., & Kaski, D. (2026). What patients do when they feel dizzy: behavioural signatures reveal diagnostic clues in common vestibular disorders. Journal of Neurology, 273(10), Article 587. https://doi.org/10.1007/s00415-026-14133-0

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14133-0

Keywords: dizziness, vestibular disorders, vestibular migraine, PPPD, BPPV, orthostatic dizziness, avoidance behaviour, coping strategies, behavioural adaptation, diagnosis, vertigo, neurology