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Chapter 6. Dizziness

Michelle V. Conde, MD; Emily Wang, MD; Mark C. Henderson, MD

A 61-year-old woman comes to your office for intermittent dizziness for the past 2 weeks. At times, she misses work due to the dizziness. When she awakens in the morning, she states, “The entire room spins.” Nausea accompanies the dizziness. The episodes last less than a minute.

  • What other components of the history are important to ask?
  • How would you classify the patient's dizziness?
  • What alarm symptoms should you ask about to determine the severity of the diagnosis?

Dizziness is classically categorized into 4 subtypes: vertigo, presyncope or syncope, dysequilibrium, and light-headedness (undifferentiated dizziness).1 However, it may be difficult to identify a single category in every patient, particularly in the elderly, who often manifest more than 1 subtype. Medications may also cause more than 1 subtype of dizziness.

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DysequilibriumImpaired walking due to difficulties with balance. It is sometimes described as dizziness “in the feet.” Formally speaking, dysequilibrium does not occur in the nonambulatory patient.
Light-headednessDizziness that is not vertigo, syncope, or dysequilibrium; this form is also called undifferentiated dizziness.
PresyncopeThe feeling that one is about to faint or lose consciousness, but actual loss of consciousness is averted. Syncope is defined as sudden, transient loss of consciousness (see Chapter 29).
VertigoAn illusion or hallucination of movement, usually rotation, either of oneself or the environment.2
Benign paroxysmal positional vertigo (BPPV)BPPV is a common peripheral vestibular disorder that is usually caused by migration of inner ear otoliths (calcific particles) to the posterior semicircular canal. The otoliths amplify any movement in the plane of the canal, resulting in brief episodes of vertigo following changes in head position.
Ménière's diseaseA peripheral cause of vertigo characterized by the triad of fluctuating hearing loss, tinnitus, and episodic vertigo. Aural fullness or pressure is often present. Excess endolymph results in increased pressure within the semicircular canals.2
Vestibular neuronitisA peripheral acute vestibular syndrome that typically lasts for a day or longer and is often accompanied by nausea, emesis, and unsteadiness.2 Some episodes are associated with a preceding infectious illness. Labyrinthitis has a similar presentation but also includes hearing loss.3
Vertebrobasilar insufficiency (VBI)Reduced blood flow to the brainstem that can manifest as the following: vertigo, cranial nerve dysfunction (eg, diplopia, hoarseness, dysarthria, dysphagia), or cerebellar dysfunction (eg, ataxia). Sensory and motor impairment may also occur. VBI (from artery-to-artery embolization, low flow, or vertebral artery dissection) may result in transient ischemic attack (TIA) or stroke.

The etiology of dizziness depends on the clinical setting. A systematic review including over 4500 patients from 12 clinical settings (primary care offices, n = 2; specialty clinics, n = 6; and emergency departments, n = 4) showed that dizziness was due to peripheral vestibular or psychiatric causes in roughly 60% of cases.4 The cause was unknown in approximately 1 in 7 patients. In contrast, in a study of ...

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