The approach to the patient with dizziness and/or vertigo requires a careful history. Vertigo, which is the illusion of movement, is highly suggestive of a peripheral vestibular disorder. After a thorough history, the physician should be able to narrow the suspected condition to a peripheral vestibular disorder, central vestibular disorder, or nonvestibular cause. Common peripheral vestibular diseases include benign positional paroxysmal vertigo, vestibular neuronitis, labyrinthitis, superior canal dehiscence and Ménière’s disease. Common central vestibular disorders include vestibular migraine, and posterior circulation (vertebrobasilar) ischemia. Nonvestibular dizziness could be due to medications, cardiac diseases, or psychogenic causes. The physical examination should include otoscopy and cranial nerve testing as well as selected cerebellar testing. Audiometry and videonystagmography are important tests, while MRI and CT may also provide helpful information. Common medications used to treat vertigo include antihistamines and benzodiazepines. Vestibular rehabilitation therapy can be useful in many peripheral and central vestibular disorders.
The approach to the dizzy patient requires a very careful history and physical examination.1 The goal of the history is to narrow the diagnosis into one of 3 categories – peripheral vertigo, central vertigo, or a likely nonvestibular cause. As the term “dizziness” and/or “vertigo” may denote different symptoms to each patient, it is often helpful to have the patient describe their symptoms without using these terms. Vertigo is the illusion of movement, which may apply to either the patient or his/her surroundings. It is highly suggestive of a peripheral vestibular cause. Symptoms of dizziness, lightheadedness, and imbalance are much less nonspecific and may or may not be due to a peripheral vestibular cause. Many physicians group these latter terms under the heading “disequilibrium.”
Many times, the single most useful localizing symptom in evaluating a patient with vertigo is a unilateral otologic complaint. Aural fullness, aural pressure, tinnitus, hearing loss, or auditory distortion usually indicates a peripheral lesion. The onset and duration of the episodes are also important to elicit, as these help point to the diagnosis. Vertigo with neurological symptoms such as headache, diplopia, slurred speech, or extremity weakness is highly likely to point to a central vestibular cause. Other general medical conditions may present with a complaint of dizziness but in fact represent metabolic or cardiovascular disturbances. Syncope, which is defined as fainting or passing out is likely reflex related (vasovagal syncope) or due to cerebrovascular diseases or cardiac disease.
It is also important to note the effect of the dizziness and vertigo symptoms on the patient’s quality of life. Those who operate complex equipment or work at heights have a much greater need to have a well-functioning balance system. The Dizziness Handicap Inventory is a useful tool to document the impact of dizziness/vertigo and the degree that it impairs the patient’s daily activities.2
Factors that precipitate or mitigate the vertigo are also important to elicit. Vertigo induced by head movements ...