Dizziness

John Muench

Dizziness is a disturbance in a patient’s subjective sensation of relationship to space. It can be the clinical presentation for many different diagnoses. It is the 15th most common reason for all visits to primary care physicians, and is especially common in the elderly (1).

Approach

Dizzy patients are best categorized as having primarily vertigo, presyncope, disequilibrium, or a more vague lightheadedness. Temporal factors, related symptoms, and the physical examination can then be used to narrow the diagnosis. Screening for a psychogenic component should be part of the workup of all dizzy patients. It is important to eliminate the rare occurrence when dizziness represents a true life-threatening emergency, but once having done so, watchful waiting can be a useful primary care strategy.

A. Dizziness types and typical causes

1. Lightheaded or giddiness (various studies indicate this group comprises between 9% and 24% of all dizzy patients) (2). Psychological presentations of dizziness are usually described more as a nonspecific lightheadedness, which may be associated with other somatic symptoms of anxiousness including perioral and extremity tingling, chest pressure, and difficulty breathing or hyperventilation. Anxiety, depression, panic disorder, and somatization can cause these symptoms.

2. Presyncope (3% to 16% of all dizzy patients) reflects cerebral hypoperfusion that impairs consciousness. Typical causes are cardiac arrhythmias, ischemic or valvular heart disease, hypertrophic cardiomyopathy, vasovagal, orthostatic hypotension, or anemia.

3. Disequilibrium (1% to 17%): Elderly patients may complain of dizziness when degenerative changes in the vestibular apparatus, vision, or proprioception make it difficult to maintain balance. This occurs when standing or walking, but generally not when sitting (a diagnostic clue). Disequilibrium can also be caused by cerebellar disease, Parkinsonism and peripheral neuropathies (e.g., from diabetes mellitus or vitamin B₁₂ deficiency).

4. Vertigo is described by patients as a spinning or whirling sensation. It is caused by pathology of the vestibular system. Peripheral vertigo is to be differentiated from central vertigo.

B. Common causes of peripheral vertigo (38% to 46%)

 1. Benign paroxysmal positional vertigo (BPPV) (12% to 23%) has very specific characteristics. A latency (2 to 20 seconds) is seen between assuming the position and the vertigo. The episode lasts less than 1 minute. Attempting several times in a row to induce the vertigo with repeated head positioning will result in less severe episodes each time (fatigability). These episodes usually self-resolve within a period of months, but can recur later. Diagnosis is confirmed with the Dix-Hallpike maneuver: With the patient supine and head and shoulders extending off the examination table, the examiner supports the head and rotates it to the one side to observe for nystagmus; then the maneuver is repeated on the other side.

2. Vestibular neuronitis (viral labyrinthitis) (3% to 9%). This condition often follows a viral upper respiratory infection (URI) in the days prior to onset. Vertigo gradually develops over minutes to hours, usually peaks within 24 hours, and then slowly resolves over several days to weeks. Head movement aggravates the symptoms. Spontaneous nystagmus is present in the acute phase. Residual unsteadiness can last for several weeks but complete recovery usually occurs within 3 months.

 3. Ménière’s disease (3% to 8%) is a syndrome characterized by spontaneous recurrent episodes of vertigo that begin with a sense of ear fullness and pressure, a roaring tinnitus, and a characteristic fluctuating low-frequency hearing loss. Vertigo rapidly follows; it peaks within minutes and subsides over several hours. Patients can have as many as thirty attacks in a year in the active phase. Initially, the hearing loss is completely reversible, but later on, a hearing deficit will remain and worsen.

 C. Typical central vestibular causes of vertigo (7% to 23%). Brainstem or cerebellar ischemia; acoustic neuroma or other central nervous system (CNS) tumors; multiple sclerosis; and basilar artery migraine can all have a component that is perceived as dizziness by patients.

 D. Differentiating serious acute central vertigo from other causes. Dizziness rarely presents a life-threatening problem unless accompanied by other focal neurologic symptoms. Be more alert with elderly patients or those with risk factors for CNS hemorrhage or ischemia. A patient with vascular risk factors who presents with severe spontaneous vertigo, profound imbalance, and especially with other neurologic symptoms, should proceed with immediate magnetic resonance imaging (MRI) to rule out a cerebellar hemorrhage or infarct (3).

History.

The patient should be allowed, in his or her own words, to describe what is meant by dizziness. A description of the first attack can be helpful. What is the time course of subsequent attacks? How long do the episodes last? How frequent are they? Do any particular positions or movements bring on episodes? Is there any associated nausea, headache, fever, hearing loss, ear pain, or tinnitus? Are there other neurologic symptoms? What medications is the patient taking?

Physical examination.

 A focused physical examination usually confirms rather than makes the diagnosis. An otoscopic examination should be done looking for impacted cerumen or signs of infection. A focused neurologic examination should be done. The patient’s eyes should be observed for spontaneous, gaze-evoked or positional nystagmus. A Dix-Hallpike maneuver should be done when BPPV is suspected. The patient should be observed walking to assess cerebellar function and disequilibrium.

Testing

A screening audiogram can sometimes be helpful to detect slight asymmetrical hearing loss the patient may not have noted. To rule out cerebellar infarct or hemorrhage, an MRI—the study of choice—should be done if the diagnosis does not become clear after a period of watchful waiting. MRI is also warranted for a persistent, unilateral hearing loss to rule out acoustic neuroma. Other ancillary tests are usually not helpful unless targeted at specific symptoms (e.g., complete blood count if anemia is suspected).

Diagnostic assessment

Because dizziness can be a somatic presentation for many diagnoses, it is important to be methodical in the workup. First, attempt to classify the dizzy patient primarily in one of the four general categories noted above. A description of near-syncope allows one to pursue causes of cerebral hypoperfusion (e.g., heart disease, dehydration, anemia). Elderly patients who have noticed a gradual inability to maintain balance while walking or standing should be evaluated for treatable causes of disequilibrium, including peripheral neuropathies, vision problems, and medication side effects. Most patients, but especially the young patient who describes a vague “swimming” lightheadedness or symptoms of panic or anxiety (e.g., shortness of breath, chest pain, or numbness in arms or legs) should be primarily questioned about feelings of depression and abnormal stressors. Finally, if a patient presents with the whirling symptoms of vertigo, assess for risk of CNS ischemia or hemorrhage by taking into account the patient’s cardiovascular risks and presence of associated neurologic symptoms. Temporal factors and physical examination maneuvers can help differentiate between the primary causes of peripheral vestibular disease—BPPV, Ménière’s disease, and vestibular neuronitis.

References

1. Sloan PD. Dizziness in primary care: results from the National Ambulatory Medical Care Survey. J Fam Pract 1989;29:33–38.

2. McGee SR. Dizzy patients: diagnosis and treatment. West J Med 1995;162:37–42.

3. Baloh RW. Dizziness: neurological emergencies. Neurol Clin 1998;16(2):305–321.

Book Source Details

• Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
• Author(s): Robert B. Taylor (editor)
• Year of Publication: 2000
• Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.

Other Book Chapters Related to Vertigo

Read excerpts from these other book chapters related to Vertigo:

Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.

More About Causes of Vertigo

• Back to symptom: Vertigo: Introduction (review 152 causes)
• Next Book Extract About Vertigo: Syncope (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• All Book Extracts: All Online Book Extracts for Vertigo

More About This Book: Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter Authors: Robert B. Taylor (editor) Publisher: Lippincott Williams & Wilkins Copyright: 2000 ISBN: 0-78172-094-X

Rate This Website

What do you think about the features of this website? Take our user survey and have your say:

Website User Survey

Medical Tools & Articles:

Next articles:

• Syncope (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• Vertigo (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
• Dizziness (Field Guide to Bedside Diagnosis)
• Syncope (Field Guide to Bedside Diagnosis)
• Dizziness (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Tools & Services:

• Bookmark this page
• Related medical articles for Vertigo:
• Take a survey relating to Vertigo
• Symptom Search
• Symptom Checker
• Medical Dictionary
• Give your feedback

Medical Articles:

• Disease & Treatments Search
• Misdiagnosis Center
• Full list of interesting articles

Forums & Message Boards

• Ask or answer a question at the Boards:
• I cannot get a diagnosis. Please help.
• Tell us your medical story.
• Share your misdiagnosis story.
• What is the best treatment for my condition?
• See all the Boards.

Enter your search terms Submit search form
Search The Web Search wrongdiagnosis.com

Common Health Mistakes

Symptom
Checker

Search Specialists by State and City