Red Flag Symptoms: Dizziness

Dr Tillmann Jacobi explores when GPs should be concerned about this common symptom.

Dizziness is a common complaint in general practice, but it is a subjective experience which can lead to misunderstandings and misperceptions.

Patients may find it difficult to describe their symptoms. Taking a careful history gives essential clues to establish the diagnosis.

Red Flag symptoms
  • Fainting, collapse
  • Hearing loss
  • Headaches
  • Vertigo
  • Chest pain
  • Behaviour changes

Normal balance is maintained by the proper function of eyes, ears, proprioceptive organs and the brain, and so uncompensated disturbances in any of these systems can cause dizziness.

True vertigo is a disorder of the vestibular system, which can be peripheral (in the ear) or central (in the brain stem).

The speed of onset and the duration are important details, because short-lived dizziness is usually harmless (e.g. postural hypotension, benign paroxysmal positional vertigo (BPPV)) compared with dizziness that lasts for hours or longer (e.g. Meniere's, labyrinth failure or central causes).

Meniere's disease
There may have been a ten-dency to overdiagnose Meniere's disease in the past, when the importance of fulfilling all the characteristic criteria was not always appreciated.

The symptoms that must be present to fulfil the diagnostic criteria are episodic rotational vertigo, fluctuating hearing loss and aural fullness/tinnitus.

The real incidence of Meniere's disease is probably less than 0.1 per cent.

Instead of Meniere's disease, alternatives such as labyrinthitis or vestibular neuronitis should be considered in cases of acute-onset dizziness.

Labyrinthitis typically follows URTIs and only causes hearing loss if the cochlea becomes involved. This does not happen with vestibular neuronitis, although it otherwise has very similar symptoms to labyrinthitis: sudden, severe vertigo with nausea and sickness for a couple of days, but few other features.

Possible Causes
  • Postural hypotension
  • BPPV
  • Meniere's disease
  • Labyrinthitis/vestibular neuronitis
  • Ototoxicity
  • Middle ear disease/labyrinth failure
  • Acute cardiovascular event or arrhythmias
  • Neurological conditions (epilepsy)
  • Head injury
  • Brain tumours (rarely) or metastatic disease

Additional signs
On examination nystagmus, a positive Romberg test (the patient loses balance when standing still with feet together and eyes closed) and any sign for possible middle ear disease (e.g. discharge) are significant.

It is important to enquire about and review any current or recently changed medication.

Check BP and gait and test the central and peripheral nervous systems. Symptomatic treatment, for example with vestibular sedatives, can be useful but does not tend to work in BPPV or if there are more complex causes.

Care should be taken when prescribing these drugs, especially to the elderly, in view of a possible increase in risk of falls. Drugs should not be prescribed without a thorough assessment of the underlying cause.

Additional symptoms with dizziness, such as sudden hearing loss and tinnitus (especially if unilateral), loss of consciousness, any neurological deficits of the central or peripheral nervous system, significant headaches, chest pains or breathlessness (not apparent reversible hyperventilation) should be noted and taken seriously.

Do not hesitate to refer or, at least, ask for another opinion in an acute scenario if you remain uncertain about the cause.

  • Dr Jacobi is a salaried GP in York

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