BE FAST — recognizing a stroke
- Balance: sudden loss of balance or coordination
- Eyes: sudden vision changes in one or both eyes
- Face: ask the person to smile — does one side droop?
- Arms: ask them to raise both arms — does one drift down?
- Speech: ask them to repeat a simple sentence — is it slurred or wrong?
- Time: if even one of these signs appears suddenly, call 911 immediately. Don't wait to see if it passes, and don't drive the person to the hospital yourself.
Call 911 even if the symptoms go away on their own. A brief episode that resolves can be a TIA — a warning stroke. About 30% of people who have a TIA have a major stroke within three months without treatment. Clot-dissolving treatment for stroke only works within a narrow window after symptoms start — note the exact time symptoms began, since responders will ask.
Why vertigo alone is confusing
Vertigo is the false sensation that the room is spinning or moving — different from general lightheadedness. It's one of the most common complaints in older adults, and the biggest danger is usually falling, not the sensation itself.
Most vertigo is not a stroke. Benign paroxysmal positional vertigo (BPPV) is the most common cause — brief episodes, usually under a minute, triggered by specific head movements like rolling over in bed or looking up, with no hearing loss and no other neurological symptoms. Vestibular neuritis causes a more severe, constant spinning sensation lasting hours to days, often with nausea and vomiting, but again without other neurological symptoms.
When vertigo is actually a stroke warning sign
Stroke can cause vertigo that looks similar to vestibular neuritis on the surface — both can cause constant vertigo, nausea, and difficulty walking for hours to days. What separates them is whether any of these appear alongside the vertigo:
- Double vision
- Slurred or difficult speech
- Weakness or numbness anywhere in the body
- A severe, sudden headache
- Trouble swallowing
- Balance loss severe enough that the patient cannot stand or walk at all
If vertigo appears alongside any of those signs, treat it as a stroke using BE FAST above — call 911 immediately. Don't wait to see if it resolves. Vertigo alone, without any of those additional signs, is very unlikely to be a stroke — but it still warrants a same-day call to the PCP, especially if it's a new or first-time episode.
A common, reversible cause: medication
Many medications prescribed to older adults can cause dizziness or vertigo as a side effect: blood pressure medications (ACE inhibitors, beta-blockers, calcium-channel blockers), diuretics, sedatives, anti-seizure medications, and antidepressants. If dizziness or vertigo started or worsened after a new medication or dose change, report it to the prescribing doctor — this is one of the more common and reversible causes, worth raising before assuming it's a new medical problem.
Fall risk
Dizziness and vertigo significantly raise fall risk in older adults, and risk climbs with the number of medications someone takes. During an active episode, the patient should sit or lie down immediately rather than try to walk it off — assist them rather than let them navigate alone until the spinning passes. Standard fall-prevention basics apply here too: clear pathways, grab bars, adequate lighting, no throw rugs.
Quick summary — when to escalate
- Call 911 for vertigo with any stroke-like sign: double vision, slurred speech, weakness, numbness, severe headache, or inability to stand or walk at all.
- Same-day call to the PCP for a new or first-time vertigo episode without stroke signs, or if it followed a recent medication change.
- Worth mentioning, not urgent: recurring brief vertigo triggered by specific head movements (rolling over, looking up) with no other symptoms — the PCP may refer for a simple in-office repositioning treatment.