The dizzy patient

Dizziness, a common presenting complaint, is sometimes problematic for more than 20% of people in their life. Patients are keen to be given a diagnosis, and despite the fact that such patients are often seen as a ‘heartsink’ by clinicians, as many as 75% of cases can be diagnosed and treated without the need for further investigations. The history is therefore of utmost importance. Although ‘grey areas’ do exist, the key aims are to differentiate vertigo from other causes of imbalance and to distinguish labyrinthine from central causes of vertigo. Clear details of the patient’s medications, recent surgery or trauma must be ascertained. The following is not a comprehensive review but gives a series of ten questions that can be used as an algorithm for the history. It is equally applicable to patients with acute and chronic forms of vertigo. 1 Does the room spin or is it just light-headedness? It is important to ask the patient to clarify their symptoms. The term ‘dizziness’ is unhelpful and should be avoided. Drachman first described a classification of ‘dizziness’ into four types. The first type is vertigo, an ‘illusion of movement’, often a spinning sensation. The second type is presyncope, a sensation of impending faint or loss of consciousness. The third type is disequilibrium, an impaired balance and gait without abnormal head sensation. The fourth type is lightheadedness, a vague term for patients not fitting into the other categories; these patients often use such terms as ‘giddiness’ or ‘wooziness’ to describe their imbalance. The possibility of a general medical disorder (e.g. cardiac arrhythmia, diabetes mellitus, thyroid disorder) should be particularly considered in patients without true vertigo. The rest of the algorithm that follows applies to patients with true vertigo. 2 Is the spinning horizontal or vertical (tumbling)? 3 Is the spinning better with the eyes open or closed? True horizontal or rotational vertigo that lessens with fixation of gaze is more likely to represent a labyrinthine pathology. Vertigo that is purely vertical or does not lessen with fixation of gaze is more suggestive of central pathology. 4 How long does the vertigo last? Vertigo lasting seconds is likely to be due to benign paroxysmal positional vertigo (BPPV), but vertebrobasilar insufficiency should be considered. Vertigo lasting minutes to hours suggests Meniere’s syndrome, and lasting hours to days suggests acute vestibular failure (infective labyrinthitis or vestibular neuronitis). Migraine and vascular events can present with vertigo of variable duration, usually hours to days. Vertigo that is constant for weeks may be psychogenic, though central lesions must be considered. Visual or proprioceptive (including cervical) impairment may cause prolonged, or frequent brief, episodes of vertigo. This often affects the older patient who may have a multi-factorial problem. 5 Are deafness and ⁄ or tinnitus directly associated with the vertigo? A presentation with prodromal aural fullness, low-tone tinnitus and hearing loss in direct association with the vertigo suggests Meniere’s syndrome. It is worth remembering, however, that other causes of vertigo can be associated with hearing loss and ⁄ or tinnitus, particularly if high pitched. 6 Does the vertigo have a positional trigger? True vertigo will always be worse with head movements. If the vertigo lasts seconds to minutes, particularly on lying with one ear downmost, BPPV is suggested. Migrainous vertigo can also be positional (‘pseudoBPPV’). 7 Has there been a recent viral illness? This type of prodromal history may suggest a viral cause for acute vestibular failure, though microvascular events are commoner. 8 Are there other symptoms associated with the vertigo? Aural fullness may suggest Meniere’s syndrome. Mild or severe headache, visual disturbance, aura and nausea may occur with vestibular migraine. Nausea is also common with peripheral vestibular disorders as part of an autonomic response. Patients experiencing transient ischaemic attacks in the vertebrobasilar system often have neurological symptoms (e.g. visual disturbance, focal weakness, dysarthria) but may present with isolated A 1 2 M I N U T E C O N S U L T A T I O N