Red flag symptoms
- Loss of consciousness
- Focal neurologic deficit
- Severe, continuous symptoms for >1 hour
Definition of dizziness
'Dizzy' may describe light-headedness, feeling unsteady (gait disturbance) or vertigo. It may be associated with nausea and vomiting or difficulty with balance. In patients presenting with dizziness, clarify what this means.
Dizziness can be acute or chronic and is more likely to present with increasing age.
The vestibular system is important in balance, and comprises the vestibular nuclei in the brain stem and cerebellum, and the vestibular apparatus in the inner ear. Conditions affecting the vestibular system can therefore cause dizziness.
Dizziness with vertigo
Benign paroxysmal positional vertigo (BPPV), Meniere's disease, vestibular neuritis and labyrinthitis may cause dizziness with vertigo. Other causes include migraine and disorders affecting visual or proprioceptive input to the brain.
Dizziness without vertigo
Dizziness without vertigo tends to be multi-factorial and may be related to drug side effects. The following conditions may produce dizziness:
- valvular heart disease
- thyroid disease
In elderly patients, dizziness may be caused by reduced proprioceptive ability, as well as reduced visual and vestibular input on a background of comorbidities.
Neurological conditions such as Parkinson's disease and peripheral neuropathy may cause unsteadiness, interpreted as dizziness. Anxiety and depression may cause light-headedness, secondary to hyperventilation.
- Central vertigo
- Intracranial bleed
- Space-occupying lesion
- Carotid or vertebral artery dissection
- Vertebrobasilar insufficiency
- Cerebellar stroke
- Peripheral vertigo
- Acute otitis media
- Meniere's disease
After clarifying what a patient means by dizziness, establish the severity of any episode and associated symptoms. The latter may include:
- hearing loss
- visual impairment
- difficulty walking due to gait disturbance
If symptoms are episodic, establishing frequency and duration is important. Exacerbating and relieving factors are relevant.
Systemic review may elucidate the underlying cause. Physical examination should include observations such as lying and standing BP, if relevant. Neurological examination should include looking for nystagmus, assessing gait and coordination, and carrying out the Romberg test. Down-beating or bidirectional gaze-evoked nystagmus indicate central nervous system involvement.
Assessment of hearing may be carried out. Vertigo associated with hearing loss may be caused by Meniere's disease or labyrinthitis; however, if vertigo occurs without hearing loss, BPPV or vestibular neuritis is likely.
Persistent vertigo may occur with vestibular neuritis or labyrinthitis, while episodic vertigo occurs in BPPV or Meniere's disease.
CVD and stroke
Cardiovascular disease may cause dizziness. Most patients with supraventricular tachycardia experience feeling dizzy. If symptoms relate to postural changes, consider orthostatic hypotension.
Cardiovascular medications may increase the risk of this occurring. Stroke or transient ischaemic attack may present with dizziness but usually other symptoms are present.
Vestibular neuritis may present with acute, severe dizziness with nausea and vomiting. This causes vertigo that may be severe for a couple of days, but resolves over weeks.
A similar clinical picture may be produced by a small stroke affecting the brain stem or cerebellum, so asking about focal numbness or weakness or slurred speech is relevant, although these may not be present.
Dizziness may affect up to half of patients with stroke at presentation in conjunction with focal neurology.
Recurrent short episodes of dizziness triggered by changes in head position may be caused by BPPV. They last less than a minute.
Central positional vertigo is caused by a lesion affecting the cerebellum or brain stem.
Cerebellar tumour, MS and migrainous vertigo may present with positional vertigo and nystagmus. Gait ataxia, dysarthria, dysdiadochokinesia and intention tremor may be features of cerebellar pathology.
Meniere's disease causes episodes of vertigo associated with hearing loss, tinnitus or ear fullness, which may last for hours.
Recurrent episodes of dizziness that last for minutes may indicate a transient ischaemic attack. If the episodes are increasing in frequency this may be suggestive of crescendo transient ischaemic attacks.
Recurrent episodes may be indicative of basilar artery occlusion. Auditory symptoms may be present as the anterior inferior cerebellar artery may be involved.
- Dr Kochhar is a GP in Bexhill-on-Sea, East Sussex. This article was updated by the author in August 2018.
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- Kerber KA. Vertigo and dizziness in the emergency department. Emerg Med Clin North Am 2009; 27(1): 39-viii.
- Tusa RJ, Gore R. Dizziness and vertigo: emergencies and management. Neurol Clin 2012; 30(1): 61-74.