This is a UKMLA-centred history guide for dizziness and vertigo.
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 the 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 sensation of a head rush.
- Unsteadiness refers to a feeling that you may fall or lose your balance.
Defining the 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?
- 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 lying – suggestive of pre-syncope
- Feeling anxious or panicked – suggestive of panic/anxiety attacks
- Exertion or while 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).
Causes of unsteadiness
Unsteadiness can represent a loss of proprioception, weakness of the lower limbs or weakness of the core muscles. The following table is a (non-exhaustive) list of examples.
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.
Causes of central vertigo
Central vertigo is caused by pathologies of the brain. Central causes of vertigo are uncommon, but often more serious.
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 nerve 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, a 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.
Author and Editor – Dr James Mackintosh
