Can dizziness and ear ringing (tinnitus) be signs of a stroke, especially in adults or elderly individuals with a history of cardiovascular disease?

Can Dizziness and Ear Ringing Be Signs of Stroke?

Yes, dizziness can be a warning sign of stroke, particularly posterior circulation stroke, but isolated ear ringing (tinnitus) alone is not a typical stroke symptom. However, when sudden dizziness occurs with sudden hearing loss or new tinnitus, this combination raises concern for vertebrobasilar stroke and requires urgent evaluation 1.

Understanding the Stroke Connection

Dizziness as a Stroke Warning Sign

The American Heart Association explicitly lists sudden trouble walking, dizziness, loss of balance or coordination as one of the cardinal warning signs of stroke 1. This is particularly important because:

• Dizziness is the most common symptom of posterior circulation transient ischemic attack (TIA) and frequently precedes posterior circulation strokes 2
• Approximately 25% of acute vestibular syndrome cases are caused by cerebrovascular disease, rising to 75% in patients with high vascular risk factors 3
• Critically, 75-80% of patients with posterior circulation stroke have no focal neurologic deficits on examination, making dizziness potentially the only warning sign 3

When Tinnitus Becomes Relevant

Isolated tinnitus without other symptoms is rarely a stroke sign. However, sudden unilateral hearing loss with tinnitus is a red flag requiring urgent neuroimaging 3, 4. Additionally:

• Pulsatile tinnitus can be a harbinger of hemorrhagic or ischemic stroke when caused by vascular abnormalities 5, 6
• The combination of dizziness, tinnitus, and hearing loss may indicate vertebrobasilar insufficiency or labyrinthine infarction 2

Critical Red Flags Requiring Immediate Evaluation

Call 911 immediately if dizziness occurs with any of these features 1, 3:

• Sudden numbness or weakness of face, arm, or leg, especially on one side
• Sudden confusion or trouble speaking
• Sudden trouble seeing in one or both eyes
• Sudden severe headache with no known cause
• Sudden hearing loss (unilateral)
• Inability to stand or walk
• Focal neurological deficits on examination

High-Risk Populations

Certain individuals face substantially elevated stroke risk when experiencing dizziness 3, 7:

Vascular Risk Factors

• Age over 50 years
• Hypertension
• Diabetes mellitus
• Atrial fibrillation
• Prior stroke or TIA
• Current smoking
• Coronary artery disease

Patients with these risk factors who develop acute persistent dizziness require MRI brain without contrast, even with a completely normal neurologic examination, because 11-25% will have posterior circulation stroke 3.

Documented Increased Risk

Emergency room patients discharged with isolated dizziness or vertigo have a 2-fold increased risk of subsequent stroke or cardiovascular events within three years compared to patients without dizziness 7. This underscores that dizziness should never be dismissed as benign without proper evaluation.

Distinguishing Stroke from Benign Causes

Timing and Pattern Matter Most

The American Heart Association emphasizes focusing on timing and triggers rather than the patient's subjective description of dizziness 1, 3:

• Seconds to minutes, triggered by head position: Suggests benign paroxysmal positional vertigo (BPPV), not stroke 3
• Days to weeks of constant symptoms: Could be vestibular neuritis (benign) OR posterior circulation stroke 3
• Minutes to hours, spontaneous episodes: May indicate vestibular migraine, Ménière's disease, or TIA 3

The HINTS Examination

For patients with acute persistent vertigo, the HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, compared to only 46% sensitivity for early MRI 3, 4. Features suggesting stroke include:

• Normal head impulse test (abnormal suggests peripheral cause)
• Direction-changing or vertical nystagmus
• Present skew deviation

When Imaging Is Necessary

Immediate MRI Brain Without Contrast Indicated For 3, 4:

• Abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome, even with normal exam
• Sudden unilateral hearing loss
• New severe headache accompanying dizziness
• Inability to stand or walk
• Progressive neurologic symptoms

Imaging NOT Needed For 3, 4:

• Brief episodic vertigo with positive Dix-Hallpike test (confirms BPPV)
• Acute persistent vertigo with normal neurologic exam AND peripheral HINTS findings in trained examiner
• Typical BPPV features without red flags

Common Dangerous Pitfalls

Pitfall #1: Assuming Normal Exam Excludes Stroke

This is the most dangerous error. Remember that 75-80% of posterior circulation stroke patients have no focal deficits 3. High vascular risk alone mandates imaging.

Pitfall #2: Relying on CT Instead of MRI

CT head has less than 1% diagnostic yield for isolated dizziness and misses most posterior circulation infarcts 3. When stroke is suspected, MRI with diffusion-weighted imaging is essential, with 4% diagnostic yield versus <1% for CT 3.

Pitfall #3: Dismissing Dizziness in Elderly Patients

Elderly patients often present atypically, with complete amnesia present in up to 40% of elderly patients with syncope 1. Multiple medications and polypharmacy complicate the picture but don't exclude stroke 1.

Pitfall #4: Overlooking Vertebrobasilar TIA

Dizziness can be more frequent before posterior circulation strokes than during the actual stroke 2. Recurrent brief episodes of dizziness in high-risk patients warrant aggressive evaluation and medical management 2.

Immediate Action Algorithm

For any adult with cardiovascular risk factors presenting with new dizziness:

1. Establish exact time of symptom onset 8
2. Assess for stroke warning signs listed above 1
3. If ANY red flag present: Call 911, transfer to stroke center, obtain MRI brain without contrast 3, 4, 8
4. If high vascular risk but no red flags: Urgent outpatient MRI within 24-48 hours 3
5. If low risk, brief episodes, positive Dix-Hallpike: Treat BPPV with Epley maneuver, no imaging needed 3, 4

Bottom Line for Quality of Life and Mortality

The window for effective stroke treatment is extremely limited—fibrinolytic therapy must be administered within the first hours of symptom onset 1. Missing a posterior circulation stroke because dizziness was dismissed as benign can result in severe long-term disability or death 1. Conversely, recognizing stroke warning signs and activating emergency services immediately can limit neurological injury and dramatically improve outcomes 1, 8.

When in doubt with dizziness in adults with cardiovascular disease, err on the side of urgent evaluation—the mortality and morbidity stakes are too high to miss a stroke 8, 7.