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Background Acute vertigo is a common but diagnostically challenging presentation in emergency departments (EDs), where rapid distinction of life-threatening conditions—like stroke—is critical. Patient and clinician perspectives are often overlooked, and real ED needs and possibilities remain poorly understood. While smartphone-based clinical decision support tools (CDSTs) show promise, evidence on required features for trust and adoption is limited. The UK’s 2025 10-Year Health Plan highlights digital innovation and AI in urgent care, underscoring the need to address these gaps.Objective To explore the experiences of emergency physicians and patients with acute vertigo during the diagnostic process; identify real-world challenges, needs and opportunities within the ED setting; and assess participants’ perceptions of the acceptability of implementing a smartphone-based decision-support tool (CDST) to aid in acute vertigo diagnosis.Design Qualitative study using semi-structured interviews and reflexive thematic analysis.Setting Emergency Department of University College London Hospitals NHS Foundation Trust (UCLH), UK.Participants 10 emergency physicians with experience in managing acute vertigo and 10 patients who had recently presented to the ED with symptoms of acute vertigo.Results The analyses identified challenges and needs when diagnosing acute vertigo in the ED and participants’ views on future smartphone-based CDST development to assist the diagnostic process. Clinicians emphasised diagnostic complexity, limited training and system-level constraints—like lack of space, time and resources—as major challenges. Patients emphasised the need for better communication and clearer diagnostic pathways. Both groups saw potential in smartphone-based CDSTs to improve diagnostic efficiency and accuracy by offering structured assessments and helping clinicians identify serious conditions.Conclusions This study offers insights into real-world constraints of diagnosing acute vertigo in the ED. Findings suggest that aligning CDST design with clinical workflows, user trust and environmental realities may facilitate adoption and impact in emergency care settings.