Introduction

Dizziness is a difficult symptom. It is a term used by patients to describe a feeling alien to them for which they cannot find a more exact description. The doctor's first job is to clarify what the patient means by dizziness. Have a look through these questions.

Do you feel as if you are spinning?

Most patients with a true vertigo immediately recognise this is what they mean. However, some patients may need clarification - for example comparing the feeling to getting off a roundabout or merry-go-round, or if you stop suddenly after spinning round and round.

If this is the sensation is it continuous or intermittent?

Intermittent vertigo:

• Is it associated with nausea and vomiting?
• Do any activities make it worse?
• Is there any relationship to movement.
• Do you have any problems with your hearing?
• Do you get a headache after the dizziness?

Patients with a clear history of positionally related vertigo almost always have benign positional vertigo. The vertigo is brief (less than one minute), triggered by movement, reduces with repeated movement and is usually associated with nausea or, if severe, occasionally vomiting. In some patients this syndrome can follow head injury. Examination is normal with the exception of Hallpike's manoeuvre (see below). This syndrome is usually easily recognisable and your doctor can make a confident diagnosis on clinical findings alone.

If a patient has had previous attacks of vertigo, has associated ringing in the ears (tinnitus) and one-sided deafness, a diagnosis of Meniere's disease is suggested. This is, however, rare and requires more formal assessment. An audiogram hearing test will show a characteristic loss of high tone hearing. This diagnosis is made with less certainty and there is no specific diagnostic test. This is an overdiagnosed condition.

Occasionally patients, usually young women, will develop a headache in association with the vertigo. The headache is throbbing and is of a migrainous type. This syndrome is called basilar migraine and responds to conventional migraine treatment.

Apart from these three entities the history and examination is directed at deciding whether the vertigo is caused by an abnormality in the brain (central) or in the balance mechanisms in the inner ear or the nerve to the ear (peripheral). Peripheral vertigo is more usually associated with nausea and usually improves gradually. On examination the doctor will look for jerky eye movements that if seen are always associated with a feeling of vertigo. When there is associated deafness, numbness or weakness of the face the doctor will be concerned about pressure on the nerve that goes to the ear and will be wanting to refer you for a head scan; these conditions are rare.

Causes of dizziness related to the brain may be associated with other symptoms - double vision, facial numbness and the doctor may observe rhythmic, jerky eye movements which are not associated with dizziness. The doctor will look for other neurological signs, such as unsteadiness when walking. Causes of these problems include multiple sclerosis in younger patients and stroke - also referred to as vertebrobasilar insufficiency - in older patients

To summarize, the main causes of intermittent vertigo are

• Benign positional vertigo (common)
• Meniere's disease (rare)
• Basilar migraine
• Brain disease like multiple sclerosis in younger patients (rare), or stroke in older patients.
• Compression of the nerve to the ear (rare)

Continuous vertigo:

How long have you felt as if you are spinning?

The brain tends to compensate for vertigo arising from the inner ear or its nerve within 4 to 6 weeks. Vertigo from the brain can persist. Continuous vertigo that has persisted over 2 months is therefore likely to arise from the brain.

However, most patients do not wait 2 months before consulting the doctor and other features must be used to distinguish between peripheral vestibular syndromes, most common of which is vestibular neuritis, from central vestibular syndromes. In both the patients feels sick and may vomit. The patients are unsteady when they try to walk. In both examination may reveal rhythmic, jerky eye movements and an unsteady gait. It may be very difficult to distinguish between them. There are a few clues.

In peripheral vestibular syndromes only horizontal, rhythmic, jerky eye movements in one direction with a slight torsional component are seen. The patient may have some unsteadiness in walking but arms and legs tend to work normally. There are no other neurological signs. Ear pathology, for example, middle ear infection, needs to be ruled out as a possible cause of a peripheral vestibular syndrome.

In central vestibular syndromes the patient may have rhythmic, jerky eye movements in one direction but often this may be seen in more than one direction. Other neurological signs may be seen especially difficulty of coordination in the limbs or sensory loss affecting part of the body.

Treatment of vertigo syndromes

Symptom control is the first requirement in central and peripheral causes of vertigo. There are a range of possible agents which work in different ways (see below). 

Antihistamines:

Major side effect drowsiness

• dimenhydrinate (Dramamine) 50mg 6 hourly
• promethazine hydrochloride (phenergan) 50mg
• cyclizine (valoid) 50mg
• cinnarizine (sturgeron) 15mg 8 hourly
• betahistine serc) 16mg 8 hourly

Anticholinergics:

Major side effects dry mouth, urinary retention etc

• hyoscine patch 1.5mg (scopoderm)

Dopamine antagonists:

Major side effects drowsiness, involuntary movements

• metoclopramide (maxalon) 10mg 8 hourly
• prochlorperazine (stemetil) 5mg 8 hourly

These agents are useful in controlling the acute symptoms, particularly while any nausea persists. Their use, especially in peripheral vertigo syndromes, slows the central compensation and therefore will delay recovery.

Further management and treatment depends on the diagnosis. Brain causes of dizziness will need further investigation as to their underlying cause - for example, risk factors for stroke.

Benign positional vertigo recovers without specific treatment, however Brandt’s exercises can speed resolution:

Brandt's exercises - the patient sits on the side of their bed and then throws themselves vigorously to one side so they are lying on their side. They then wait till any vertigo has passed and then to throw themselves to the other side. They should repeat this manoeuvre until no further vertigo is provoked 3 or more times a day.

Continuous vertigo

Causes of ear or nerve related continuous dizziness

• inner ear inflammation

Causes of brain related continuous dizziness:

• Young - multiple sclerosis
• Old - posterior circulation stroke

Do you get a dimming of vision or a feeling you are going to blackout?

These are warning symptoms of an impending faint, and are further evaluated in the same way as episodes of fainting.

• Do you only get the attacks when standing or sitting?
• Do the attacks only occur after standing quickly?
• Will lying down make the feeling go away?
• Do people tell you that you go pale?
• Do you feel hungry during the attacks?
• Do you get palpitations before or during the attack?
• What tends to bring the attacks on?
• When do the attacks occur, what are you doing when they come on?

Usually the patient has had a number of attacks before seeking medical help. The doctor will try to clarify the nature of the attacks, preferably including an account from a witness, secondly to try to find other symptoms that accompany the attacks to try to find things that trigger the episodes or situations in which the attacks occur.

In many situations a specific diagnosis can be suggested from the history: fainting attacks in teenagers and young adults which occur when hot, after prolonged standing often triggered by emotional stress, feeling faint associated with cough or passing urine - usually all these types of attack lead to loss of consciousness.

A feeling of lightheadness on standing suggests that your blood pressure drops on standing, commonly due to drugs given for high blood pressure or dehydration, but occasionally due to nerve damage such as that associated with diabetes, and very rarely diseases such as Addison's disease. A feeling of hunger suggests low blood sugar, which is rare in all except diabetics on treatment. Palpitations suggest the cause may be a heart rhythm abnormality. If the feeling is brought on by exercise there may be a problem with heart valves or muscle.

Examination is usually unhelpful. However, the doctor will check the pulse, standing and lying blood pressure and listen to your heart.

Do you feel distant and unable to communicate during the your dizzy spells?

Some patients refer to attacks of impairment of consciousness as 'dizzy turns'. The patients usually recognise that they are distant and unable to communicate.

• How long do the attacks last?
• Are the attacks all the same?
• Do you get a funny feeling in your tummy, an odd smell or a feeling of deja vu with the attacks?
• Has one seen you during an attack?

Patients with stereotyped attacks of altered consciousness often are found to have a type of epilepsy. If there are sensations of abnormal smells or abdominal discomfort this is very strongly suggestive. However it is essential to try to obtain a witnessed account of an attack - taking particular notice of chewing movements, picking with the hands or repetitive actions, pointing as these may help determine where the problem is. Bring a relative or friend who has seen one of these attacks with you when you see the doctor. A distant feeling is often reported by patients who hyperventilate (breath to fast and deep) but most of these patients recognise that they would be able to reply if spoken to.

Do you feel unsteady when you walk - but your head feels clear?

Some patients who complain of dizziness in fact mean their walking is unsteady.

Patients usually recognise that this is what they mean by dizziness when it is suggested them. Problems that can present in this way are:

• nerve damage (e.g. due to diabetes)
• brain disease
• Parkinson's disease

If the answer to the previous main questions is no:

Some patients fail to recognise their symptoms in the brief descriptions given above, or further attempts to characterise their problem, - which seemed to have fallen into one of the groups above fails.

To try to clarify matters further with this group:

• When do the attacks occur?
• Do you feel thirsty or breathless when you feel dizzy?
• Do you ever get numbness in your hands, feet or face?
• Do you get palpitations with the attacks?

In some patients the dizziness may be quite hard to characterise. However, the occurrence of attacks, at least when the symptom first develops, at times of stress, following bereavement, in difficult situations at work, suggest there may be a psychogenic component. Once the symptom is established the dizziness can occur at any time. The majority of patients also have features that suggest they may be hyperventilating - sometimes a clear description of breathlessness or a need to breath deeply, sometimes they merely notice they are thirsty during the attacks. Tingling in the hands, feet and around the mouth is also characteristic. Palpitations often occur with the attacks but usually do not precede the dizziness. Palpitations of these patients is normal and forced hyperventilation for 1-3 minutes (with 20 breaths or more a minute) usually reproduces a mild attack.

The majority of patients improve once they recognise the cause of their symptoms. However, management requires not only that the patient learns strategies to control the breathing (e.g. counting, drinking at the onset of the attack) but also that the underlying trigger is recognised and this problem also addressed.

Key points on examination of a dizzy patient

Your doctor will probably want to check the following if you present with dizziness:

• Gait - including walking heel toe
• Eye movements - especially nystagmus (rhythmical, jerky eye movements)
• Ear examination - hearing and ear drum inspection
• Coordinaton tests - finger nose and heel shin tests
• Lying and standing blood pressure
• Hallpike's manoeuvre
• Forced hyperventilation

Hallpike's test:

This is used in patients with positional vertigo. The patient sits on a flat bed so that when he/she lies down his head will not be supported. The head is turned to one side and the patient asked to look to that side. The patient then lies back quickly till he/she is flat with their neck below the end of the couch with the head supported by the doctor. The doctor will want to look for rhythmical, jerky eye movements so will ask you to keep your eyes open. They usually start after a delay of about ten seconds and you feel dizzy - this usually settles quickly if the problem is benign positional vertigo.