Dizziness and Vertigo

Dizziness is a common complaint for which patients seek medical advice. Dizziness is typically defined as one of four types: vertigo, lightheadedness, disequilibrium, [Page 545]and presyncope. Differentiation of these types is necessary in the diagnosis, management, and treatment. However, this can be challenging because symptoms associated with each of these conditions (including nausea, vomiting, and diaphoresis) may be difficult for patients to describe. Additionally, comorbid chronic conditions over time may confound the picture. It is difficult sometimes to discern if symptoms are related to an acute illness or a new symptom of a chronic disease.

The differential diagnosis of the symptom of dizziness is large and may be a side effect of many of the body's systems. Seizure disorders may present with dizziness as a symptom, as well as psychiatric disorders and motion sickness. Ear disorders including otitis media and impacted cerumen may also present with dizziness.

Vertigo specifically is the illusion of movement (typically rotational motion). Vertigo is also the most prevalent type of dizziness. It is important to differentiate whether the symptoms of vertigo are from peripheral vestibular causes, from central causes, or from other conditions such as drug side effect or chronic neurologic disease.

To determine if the patient truly has vertigo or another type of dizziness, it is common to inquire if the patient “feels lightheaded” or if “the room appears to be spinning around.” Often, patients with true vertigo will respond that the room appears to be spinning.

An accurate history must be performed to help narrow the differential diagnosis. Inquiring about the timing and duration of the dizziness, exacerbating and remitting factors, associated neurologic symptoms, and any hearing loss should be performed as well as queries about medications, toxic exposures, and trauma.

Diagnosis of dizziness and vertigo further depends upon physical examination, with particular attention to examination of the head and neck, cardiovascular system, and neurologic findings. Orthostatic changes in systolic blood pressure and pulse may identify patients with underlying dehydration or autonomic dysfunction, in addition to changes in blood pressure resulting from medical treatment of hypertension. Orthostatic hypotension, defined as a drop in blood pressure of at least 20 mm Hg systolic or 10 mm Hg diastolic within three minutes of standing may be diagnostic of the problem. Additionally, a resting pulse >100 may indicate some volume depletion. Irregularity of the pulse which includes both bradycardia, or slowing of the heart, and tachycardia, or increasing the speed of the heart rate, may further contribute to underlying cardiovascular abnormalities that may lead to vertigo as a symptom of presyncope, or an actual syncopal, episode.

Dizziness is typically defined as one of four types: vertigo, lightheadedness, disequilibrium, and presyncope.

The Dix-Hallpike maneuver may assist in the diagnosis of benign paroxysmal positional vertigo (BPPV). Because this procedure sometimes provokes the symptoms, the patient must be aware that the symptoms may temporarily worsen while performing the procedure. Through some specific movements, the physician moves the patient's head from an upright position to a supine position, resulting in minimal hyperextension of the neck. A positive test results in horizontal nystagmus which changes direction when the patient sits upright again. Although a positive Dix-Hallpike maneuver may be helpful to differentiate the diagnosis of patients with vertigo, it is not absolutely pathognemonic for BPPV.

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