Vestibular symptoms, including dizziness, vertigo, and unsteadiness, are common presentations in the emergency department. Most cases have benign causes, such as vestibular apparatus dysfunction or orthostatic hypotension. However, dizziness can signal a more sinister condition, such as an acute cerebrovascular event or high-risk cardiac arrhythmia. A contemporary approach to clinical evaluation that emphasizes symptom duration and triggers along with a focused oculomotor and neurologic examination can differentiate peripheral causes from more serious central causes of vertigo. Patients with high-risk features should get brain MRI as the diagnostic investigation of choice.