Dizziness is a common complaint and has a very broad list of possible underlying causes. Dizziness is a nonspecific term which can mean true vertigo, light-headedness, weakness (neurological impairment), unsteadiness, feeling faint (presyncope), funny turns, visual disturbance, or a psychological problem.
Dizziness is often dismissed as a trivial symptom. However, patients often experience significant social and occupational morbidity, and establishing the diagnosis is essential in view of the wide variety of possible causes and also to enable effective management. It is essential that patients who present with dizziness should be given the correct diagnosis, both to avoid missing serious neurological causes and to ensure that the right treatment is given.
Expensive investigations are rarely helpful in dizzy elderly people. The cause of the dizziness can be diagnosed in most cases on the basis of a thorough clinical history and examination and often does not require hospital referral.
Causes of dizziness
The most common causes of true vertigo encountered in primary care are labyrinthitis or vestibular neuronitis, benign paroxysmal positional vertigo (BPPV), vestibular migraine and Ménière's disease. Even in the elderly, an underlying cause for dizziness can usually be established.
- Following head injury.
- Multiple sclerosis.
- Brain tumours, especially brainstem and cerebellar tumours.
- Benign intracranial hypertension.
- Normal pressure hydrocephalus.
- Peripheral neuropathy (imbalance or unsteadiness may occur as a result of peripheral neuropathy, spinal posterior column lesions or cerebellar disease).
- Ménière's disease.
- Vestibular neuritis and labyrinthitis.
- Vestibular migraine (generally presents with attacks of spontaneous or positional vertigo lasting seconds to days, with associated migraine symptoms).
- Otosclerosis and Paget's disease of bone.
- Middle ear trauma.
- Following surgery - eg, stapedectomy, cochlear implant.
- Tumours, cholesteatoma.
- Psychogenic: eg, generalised anxiety, agoraphobia, panic attacks, hyperventilation.
- Viral illness.
- Migraine headaches.
- Other infections - eg, acute bacterial infections, Lyme disease, HIV infection.
- Ocular: visual impairment.
- Cervical - eg, cervical spondylosis.
- Multisensory dizziness syndrome: occurs when there are reduced inputs from more than one sensory system - eg, reduced vision, vestibular dysfunction, peripheral neuropathy, autonomic neuropathy.
- Autoimmune/connective tissue disorders - eg, rheumatoid arthritis, systemic lupus erythematosus.
- Drug intoxication - eg, acute intoxication with alcohol or drugs; carbon monoxide poisoning; chronic alcohol misuse.
- Iatrogenic: side-effect of medication - eg, antihypertensives, antidepressants, aminoglycoside antibiotics, anti-arrhythmics.
Red flag signs associated with acute dizziness that indicate a possible central neurological cause (such as posterior circulation stroke) include:
- Abnormal neurological symptoms or signs
- New headache
- A normal vestibulo-ocular reflex as assessed by the head impulse test (which would imply that the vertigo does not originate in the peripheral vestibular system).
See also separate article Neurological History and Examination. A thorough history and examination usually provide a clear guide to initial investigations, treatment and the need for referral. When the patient first presents, it is really important to determine exactly what the patient is experiencing, because patients mean different things by the term 'dizziness'.
- An assessment for any serious underlying disorder requiring urgent treatment - eg, ischaemic heart disease, cerebrovascular disease.
- Identifying the nature of the presenting symptom in terms of being true vertigo, syncope, presyncope or any other form of dizziness. Dizziness can usually be categorised into one of four main groups:
- Vertigo is defined as an abnormal sensation of movement, either of the surroundings or the person (see also separate article Vertigo). Descriptions of vertigo include spinning, tilting, and moving sideways.
- Most cases seen in primary care are due to peripheral vestibular disorders such as BPPV, acute vestibular neuronitis and Ménière's disease, but causes also include central nervous system disorders such as vascular incidents or multiple sclerosis.
- A feeling of light-headedness, muscular weakness and feeling faint. Features may suggest a specific diagnosis.
- See separate article Syncope.
- A sensation of unsteadiness, not localised to the head, that occurs when walking and is relieved with rest.
- The most common cause of disequilibrium is 'multiple sensory deficits' in elderly patients, who may have deficits with all three balance-preserving senses, ie vestibular, visual and proprioceptive.
- Nonspecific dizziness:
- Many patients with dizziness do not have specific features of vertigo, disequilibrium or presyncope.
- The history is vague beyond a complaint of dizziness and there are no features that would point to causes in one of the other categories.
- Identification of the precise underlying cause, if possible.
- Actions that provoke symptoms may include:
- Change in posture (suggests postural hypotension).
- Movement of the head or neck (suggests vertigo from any cause, cervical spondylosis or vertebral artery syndrome).
- Feeling anxious (may indicate hyperventilation).
- Associated symptoms may include:
- Features suggestive of epilepsy, which need to be considered.
- Falls: refer elderly patients to a geriatrician.
- Tinnitus or hearing impairment: suggests a vestibular cause.
- Olfactory hallucinations and amnesia, which may suggest a temporal lobe lesion.
- Determine the level of anxiety: anxiety is often present in elderly patients but is not usually the only cause.
- Consider a possible cardiovascular cause; ask about smoking and any other risk factor for cardiovascular disease.
- Review past medical history and drugs being taken.
The primary aim of the bedside evaluation of a dizzy patient is the detection of any vestibular deficits.Careful examination is required in order to assess a possible underlying cause - for example:
- Cardiovascular (see also separate article Cardiovascular History and Examination):
- Blood pressure: sitting position, and also supine and standing, to assess any significant postural drop suggesting postural hypotension.
- Aortic murmur (may suggest aortic stenosis and therefore prompt cardiology referral), carotid bruit.
- Eyes (see also separate articles Examination of the Eye and Nystagmus):
- Visual impairment
- Dix-Hallpike test (see separate article Benign Paroxysmal Positional Vertigo).
- Neurological (see also separate articles Abnormal Gait and Cerebellar Disorders):
- Features of cerebrovascular disease, peripheral neuropathy or Parkinsonism.
- Examine gait and ask the patient to do heel to toe walking - if these are abnormal, test reflexes and tone in the lower extremities, and test plantar responses.
- Test co-ordination by asking the patient to put the opposite heel on the knee and to run the foot down and up the shin (assuming the patient is physically able to do this).
The most useful diagnostic approach in distinguishing different types of dizziness is a thorough history and physical examination and additional tests are rarely necessary.
However, if the diagnosis is still not obvious, then consider referral to secondary care. Initial investigations may include:
- Urinalysis: to exclude urinary tract infection.
- FBC: anaemia; mean cell volume (MCV) can be elevated with alcohol abuse.
- Renal function, blood glucose, electrolytes, LFTs.
- ECG and ambulatory 24-hour ECG for possible arrhythmia.
Further investigations may include electroencephalography (EEG), CT or MRI brain scan, pure tone audiometry, vestibular function tests (eg, electronystagmography), further cardiology investigations (eg, echocardiogram) or other investigations suggested by the presentation of each individual patient.
However, computed tomography has poor sensitivity in acute stroke, and a MRI scan can miss up to one in five strokes in the posterior fossa in the first 24–48 hours.
A three-component bedside oculomotor examination - HINTS (horizontal head impulse test, nystagmus and test of skew) - has been shown to identify stroke with high sensitivity and specificity in patients with acute vestibular syndrome and rules out stroke more effectively than early diffusion-weighted MRI.
Management depends on the underlying cause but, in general terms, management includes:
- Thorough discussion with the patient and explanation of the problem and any underlying cause.
- Evaluation and correction or amelioration of any associated medical problem.
- Drug treatment for symptoms of vertigo and any associated nausea, vomiting, sweating or diarrhoea. Great care should be given in prescribing drugs, especially to the elderly, in view of potential sedative effects and possible increase in risk of falls. Drugs should not be prescribed without a thorough assessment of the underlying cause of the dizziness. Drugs that might be used include:
- Anti-emetics - these include hyoscine, prochlorperazine, promethazine and metoclopramide (drugs may need to be prescribed as suppositories or to be taken via the buccal membrane).
- Calcium-channel antagonists, cinnarizine and cyclizine have vestibulosuppressant effects.
- Vestibular rehabilitation, including correction of remedial problems, a general fitness programme, specific exercises to make the balance system less sensitive, psychological assessment and realistic family, social and occupational goals.
- Psychological intervention - eg, cognitive behavioural therapy.
- Surgery is rarely indicated but might be required for:
Further reading and references
Management of dizziness and vertigo; Imperial College London, Department of Medicine
Kaski D, Bronstein AM; Making a diagnosis in patients who present with vertigo. BMJ. 2012 Sep 3345:e5809. doi: 10.1136/bmj.e5809.
van Leeuwen RB, Bruintjes TD; Dizziness in the elderly: Diagnosing its causes in a multidisciplinary dizziness unit. Ear Nose Throat J. 2014 Apr-May93(4-5):162-7.
Post RE, Dickerson LM; Dizziness: a diagnostic approach. Am Fam Physician. 2010 Aug 1582(4):361-8, 369.
Huh YE, Kim JS; Bedside evaluation of dizzy patients. J Clin Neurol. 2013 Oct9(4):203-13. doi: 10.3988/jcn.2013.9.4.203. Epub 2013 Oct 31.
Molnar A, McGee S; Diagnosing and treating dizziness. Med Clin North Am. 2014 May98(3):583-96. doi: 10.1016/j.mcna.2014.01.014.
Tarnutzer AA, Berkowitz AL, Robinson KA, et al; Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Jun 14183(9):E571-92. doi: 10.1503/cmaj.100174. Epub 2011 May 16.
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