History

The medical history is used to determine if true vertigo exists. Although usually described as the environment spinning, any sensation of disorientation in space or sensation of motion can qualify as vertigo. Some nausea, vomiting, pallor, and perspiration accompany almost all but the mildest forms of vertigo. A sensation of imbalance often accompanies vertigo, and this can be extremely difficult to distinguish from true instability until after the patient’s symptoms have been reduced by treatment. True instability, disequilibrium, or ataxia indicates a higher likelihood of a central process.⁷ Because the labyrinth has no effect on the level of consciousness, the patient should not have an associated change in mentation or syncope.

The time of onset and the duration of vertigo are important clues to the cause. Episodic vertigo that is severe, lasts up to several hours, and has symptom-free intervals between episodes suggests a peripheral labyrinth disorder. Vertigo produced primarily by a change in position also suggests a peripheral disorder, usually BPPV.

The presence of auditory symptoms suggests a peripheral cause of the vertigo, as in middle and inner ear problems. The ear with abnormal hearing is usually on the side of end-organ disturbance. Although vertigo can occur with acoustic neuroma, it is usually a progressive unilateral hearing loss, typically of several months’ duration, that prompts the patient with acoustic neuroma to seek medical attention. Hearing loss, vertigo, and tinnitus form the characteristic triad of Ménière’s disease.

Head injury can cause vertigo occasionally from intracerebral injury and more commonly from labyrinth concussion. Neck injury can cause vertigo from vertebral artery dissection, resulting in posterior circulation ischemia.⁸

Vestibular neuritis and labyrinthitis are very similar, though in labyrinthitis hearing is affected. Patients often develop continuous vertigo that can be worsened by movement and may take several months to fully resolve.

Are there associated neurologic symptoms? The patient or family members should be questioned about the time of onset of ataxia or gait disturbances. Ataxia of recent and relatively sudden onset suggests cerebellar hemorrhage or infarction in the distribution of the posterior inferior cerebellar artery or the superior cerebellar artery. Ataxia that is slowly progressive suggests chronic cerebellar disorders. True ataxia may be difficult to discern from the unsteadiness that occurs when a patient with significant vertigo attempts to walk, though other findings such as nystagmus and dysmetria can often help narrow the differential diagnosis. The symptom of imbalance raises the likelihood of TIA and stroke. Isolated vertigo can be the only initial symptom of cerebellar and other posterior circulation bleeds, transient ischemic attacks (TIAs), and infarction.9,10 One study showed that emergency physicians often did not make the correct diagnosis in patients with validated strokes or TIAs whose presenting symptom was only vertigo.⁷ Identifying these individuals is a significant and important challenge for clinicians taking care of vertiginous patients. The vast majority of patients with isolated dizziness do not have TIA or stroke, but the risk of not identifying the few who do is significant for ultimate patient outcomes. Stroke has been seen in 3.2% of patients with dizziness syndrome, but only 0.7% of those with isolated dizziness had a stroke.⁷ A recent study also showed that fewer than 1 in 500 patients discharged with a diagnosis of dizziness or vertigo experienced a major vascular event in the month after discharge.¹¹