Dizziness/vertigo

Probability diagnosis

Anxiety-hyperventilation

Postural hypotension

Simple faint—vasovagal

Acute vestibulopathy (V)—viral illness

Benign paroxysmal positional vertigo (V)

Motion sickness (V)

Post head injury (V)

Cervical dysfunction/spondylosis

Note: V = vertigo

Serious disorders not to be missed

Neoplasia/cancer:

• acoustic neuroma

• posterior fossa tumour

• other brain tumours, primary or secondary

Intracerebral infection (e.g. abscess)

Cardiovascular:

• arrhythmias

• myocardial infarction

• aortic stenosis

Cerebrovascular:

• vertebrobasilar insufficiency

• brain stem infarct (e.g. PICA thrombosis)

Multiple sclerosis

Pitfalls (often missed)

Ear wax-otosclerosis

Arrhythmias

Hyperventilation

Alcohol and other drugs (incl. illicit, e.g. cocaine)

Cough or micturition syncope

Vertiginous migraine/migrainous vertigo

Parkinson disease

Meniere syndrome (overdiagnosed)

Rarities:

• Addison disease

• neurosyphilis

• autonomic neuropathy

• hypertension

• subclavian steal

• perilymphatic fistula

• Shy–Drager syndrome

Masquerades checklist

Depression

Diabetes (hyper and hypoglycaemia)

Drugs (several)

Anaemia

Thyroid disorder (possible)

Spinal dysfunction

UTI (possible)

Is the patient trying to tell me something?

Very likely. Consider anxiety and/or depression.

Key history

Careful history to determine if the problem is vertigo or pseudovertigo (giddiness, faintness or disequilibrium). Check for neurological symptoms, aural symptoms and visual symptoms. Recent history of respiratory infection or head injury. Drug history including illicit drugs and alcohol (?acute intoxication).

Key examination

• General examination including gait

• Cardiovascular, auditory and neurological examinations

• Hallpike manoeuvre and Epley test

• Forced hyperventilation test

Key investigations

• FBE

• b glucose

• audiometry

• ECG, ?Holter monitor

• Other tests according to history and examination

• Consider MRI, especially if acoustic neuroma or other tumour suspected

Diagnostic tips

• A sudden attack of vertigo in a young person after a recent URTI suggests vestibular neuronitis.

• Dizziness is often multifactorial, especially in the elderly.

• Commonly prescribed drugs, especially antihypertensives, antidepressants, aspirin and salicylates, glyceryl trinitrate, benzodiazipines, major tranquilisers, antiepileptics and antibiotics, can cause dizziness.