Dizziness and Vertigo History
Author – Dr James Mackintosh Editor – Dr James Mackintosh
Last updated 30/08/2024
Table of Contents
Introduction
Dizziness and vertigo are common presenting complaints in general practice and the emergency department. Dizziness is a term often used to describe a variety of symptoms including vertigo, pre-syncope, unsteadiness and light-headedness. Vertigo specifically refers to the false sensation of spinning or rotating of either the person or their surroundings in the absence of actual movement. Causes of vertigo can be divided into peripheral and central causes. Peripheral causes affect the inner ear and central causes affect the brain.
Presenting Complaint
Defining Symptomology
First clarify what the patient means when they report ‘dizziness’ or ‘light-headedness’.
Vertigo specifically refers to the false sensation of spinning or rotating of either the person or their surroundings in the absence of actual movement. Ask they patient if it feels like the room is spinning.
Pre-syncope is the sensation that you about to lose consciousness. Patients may describe feeling woozy, light-headed or getting a head rush.
Unsteadiness refers to a feeling that you may fall or lose your balance.
By defining their presenting complaint in this way allows you to narrow down the potential causes as discussed further on in this article.
Timing
How frequently is the patient experiencing their symptoms?
How long do the symptoms last?
These questions give you a sense of how significantly the patient’s life is affected.
When did the symptoms start?
Did this coincide with a change in medication? – may suggest a causative agent
Was this preceded by a viral infection?- suggestive of labyrinthitis or vestibular neuronitis
Precipitating Factors
Turning over in bed or rotating head – suggestive of Benign positional paroxysmal vertigo (BPPV) or Meniere’s
Positional change such as going from lying/sitting to standing or sitting up from laying – suggestive of pre-syncope
Feeling anxious or panicked – suggestive of panic/anxiety attacks
Exertion or whist exercising – suggestive of dehydration, hypoglycaemia, hypotension or dysfunctional breathing such as hyperventilation or breath holding
Vomiting or Valsalva manoeuvre – suggestive of vasovagal syncope
Associated Symptoms
Symptoms often associated with pre-syncope:
Palpitations
Chest pain
Shortness of breath
Blurred vision
Symptoms often associated with peripheral causes of vertigo:
Hearing loss
Tinnitus
Aural fullness
Symptoms often associated with central causes of vertigo:
Headaches
Nausea
Weakness
Slurred speech
Vision changes
Symptoms often associated with unsteadiness:
Stumbling
Leg weakness
Altered sensation in lower limbs
Mal-coordination
Causes
We can split causes of dizziness and vertigo into pre-syncope, unsteadiness, peripheral vertigo and central vertigo. Common and serious causes of dizziness and vertigo are listed below.
Causes of pre-syncope
Pre-syncope is often suggestive of reduced cerebral perfusion. This can be caused by reduced preload (low system volume, pooling of blood in legs) or reduced cardiac output (pump failure, outflow narrowing, autonomic dysfunction).
| Differential | Typical Features |
|---|---|
Anaemia | Light-headedness worse on standing, chest pain, palpitations, shortness of breath, pallor, fatigue may report bleeding, chronic disease or deficiencies in iron, folate or B12. |
Hypovolaemia | Symptomatic when standing up, reduced input or increased output such as diarrhoea or vomiting. |
Venous insufficiency | Blood pools in legs when and causes drop in blood pressure on standing, may report swollen ankles and skin changes such as leg ulcers. |
Medications such as diuretics, antihypertensives, antidepressants, tamsulosin etc | Diuretics reduce system volume.
Antihypertensives reduce baseline blood pressure through various mechanisms, tamsulosin is an alpha blocker and reduces blood pressure. Antidepressants can cause autonomic dysregulation. |
Heart Failure | Shortness of breath on exertion, swollen ankles, breathlessness when lying flat, fatigue. |
Aortic stenosis | Classic triad of syncope, angina, and dyspnoea. |
Parkinson's Disease | Bradykinesia, unilateral tremor, micrographia, depression, rigidity and orthostatic hypotension. |
Causes of unsteadiness
Unsteadiness can represent a loss of proprioception, weakness of the lower limbs or weakness of the core muscles. The below table is not an exhaustive list of examples.
| Differential | Typical Features |
|---|---|
Diabetic neuropathy | Background of diabetes, loss of sensation and proprioception in glove and stocking distribution. |
Sciatica | Electric shock pain shooting from buttock down back of leg, can cause weakness leading to leg giving way and/or foot drop. |
Foot drop | Injury to deep fibular nerve causing paralysis of anterior lower leg muscles and no dorsiflexion. Inability to dorsiflex when walking may cause tripping or mis-stepping. |
Muscle strain | A strain of leg muscles, abdominal muscles of lower back muscles can result in weakness and this causes instability. |
Parkinson's Disease | Bradykinesia, unilateral tremor, micrographia, depression, rigidity and orthostatic hypotension. |
Causes of peripheral vertigo
Peripheral vertigo is caused by inner ear pathology that affects the vestibular nerve or labyrinth. Peripheral causes of vertigo are much more common than central causes.
| Differential | Typical Features |
|---|---|
Benign Positional Paroxysmal Vertigo | Vertigo when turning over in bed or rotating head. Positive Dix-Hallpike examination. |
Meniere's disease | Fluctuating sensorineural earing loss, vertigo attacks that may last days, aural fullness, roaring tinnitus. |
Labyrinthitis | Proceeding viral infection, vertigo, hearing loss, headache, sensation of pressure in ear, nausea, tinnitus. |
Ramsay Hunt Syndrome | Aural vesicles, vertigo, unilateral facial weakness/paralysis, otalgia, hearing loss, tinnitus. |
Vestibular neuronitis | Rotational vertigo that is initially constant, recent viral infection, nausea, lasts 2-6 weeks. |
Cholesteatoma | Ear discharge, hearing loss, vertigo, otalgia. |
Causes of central vertigo
Central vertigo is caused by pathologies of the brain. Central causes of vertigo are uncommon, but often more serious.
| Differential | Typical features |
|---|---|
Migraine | Headache, proceeding aura, nausea, photophobia. |
Posterior circulation stroke | Acute, persistent, continuous vertigo with nystagmus, nausea, head motion intolerance, and new gait unsteadiness. Focal neurological deficit, dysarthria, unilateral limb weakness, blurry vision. |
Acoustic neuroma | Gradual unilateral hearing loss, vertigo, facial numbness and tinnitus. |
Multiple sclerosis | Fatigue, blurred vision, mal-coordination, paraesthesia, urinary incontinence, mood disturbance and cognitive decline. Most commonly affects women aged 20-40. |
Cerebellar tumour | DANISH symptoms: dysdiadochokinesia, ataxia, nystagmus, intension tremor, slurred speech and hypotonia. |
Red Flags
If you think that your patient has true vertigo it is important to establish if it has a peripheral or central cause. If you suspect a central cause you should urgently refer the patient for further assessment in secondary care.
- Features suggestive of peripheral vertigo:
- Sudden or insidious onset
- Intermittent symptoms
- Intense severity
- Headache uncommon
- Cranial nerves intact
- Symptoms worse with head movement
- Features suggestive of central vertigo:
- Sudden onset
- Symptoms commonly persistent/ constant
- Poorly defined severity
- Headache possible
- Cranial nerves deficiency may be present
- Symptoms may be worse with head movement
The following features of central vertigo should be considered ‘red flags’ and warrant urgent brain imaging:
- Isolated, persistent (>24 hours) vertigo of hyperacute (seconds) onset.
- Normal head impulse test.
- New onset headache.
- New onset unilateral deafness.
- Cranial nerve weakness or sensory loss, or limb weakness or sensory loss.
- Severe ataxia
(as per NICE CKS)
Background
In any history you will ask about past medical history, medications, allergies, social history, and family history. In a history dizziness or vertigo, you can show how much you know about the various causes by explicitly asking about the following things:
Past Medical History
- Optic neuritis can accompany the first presentation of MS.
- Recurrent otitis media is a risk factor for developing a cholesteatoma.
- Recent upper respiratory tract infections can precipitate vestibular neuronitis, labyrinthitis and BPPV.
- Hypertension, atrial fibrillation, diabetes and hyperlipidaemia are risk factors for stroke and TIA.
Family History
- Having a parent with neurofibromatosis type 2 is a risk factor for acoustic neuromas.
- Migraines often run in families.
Medications
- Bisphosphonate use is a risk factor for developing a cholesteatoma.
- Diuretics reduce system volume and drop baseline blood pressure.
- Antihypertensives reduce baseline blood pressure.
- Aminoglycoside toxicity can cause vertigo via vestibular ototoxicity.
- Antidepressants can cause autonomic dysregulation leading to dizziness.
- Tamsulosin is an alpha blocker and reduces blood pressure.
Social History
- Prolonged alcohol excess can lead to B12 deficiency resulting in anaemia or peripheral neuropathy.
- Acute alcohol intoxication can cause imbalance, dysarthria and confusion.
- Patients who smoke, have increased alcohol intake, sedentary lifestyle and obesity are at increased risk of strokes and TIAs
Examination
Examination of a patient reporting dizziness or vertigo should include a lying and standing blood pressure, otoscopy, fundoscopy and a neurological examination. You can consider doing a HINTS exam or special tests such as Romberg’s test, Rinne’s and Webber’s, or a Dix-Hallpike manoeuvre.
- NICE CKS – Vertigo – https://cks.nice.org.uk/topics/vertigo/background-information/causes/
- NHS Inform – Labyrinthitis – https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/labyrinthitis/
- Patient Info – Vertigo – https://patient.info/signs-symptoms/dizziness/vertigo#what-causes-vertigo
- Mayo Clinic – Ramsay Hunt syndrome – https://www.mayoclinic.org/diseases-conditions/ramsay-hunt-syndrome/symptoms-causes/syc-20351783
- Core EM – Posterior circulation stroke – https://coreem.net/core/posterior-circulation-stroke/
- Mayo Clinic – Acoustic neuroma – https://www.mayoclinic.org/diseases-conditions/acoustic-neuroma/symptoms-causes/syc-20356127