Posted by: Thixia | June 21, 2008

Dizziness, Vertigo, and Imbalance Section 2 of 8



The patient’s history is critical in the evaluation of the patient with dizziness.  Ask the patient to describe their symptoms by using words other than “dizzy.” The rationale for using other words is that patients may use dizzy nonspecifically to describe vertigo, unsteadiness, generalized weakness, syncope, presyncope, or falling. 

A critical distinction is differentiating vertigo from nonvertigo.  Vertigo is the true rotational movement of self or the surroundings.  Nonvertigo includes light-headedness, unsteadiness, motion intolerance, imbalance, floating, or a tilting sensation.  This dichotomy is helpful because true vertigo is often due to inner-ear disease, whereas symptoms of nonvertigo may be due to CNS, cardiovascular, or systemic diseases.

Sudden onset and vivid memory of vertiginous episodes are often due to inner-ear disease, especially if hearing loss, ear pressure, or tinnitus is also present.  Gradual and ill-defined symptoms are most common in CNS, cardiac, and systemic diseases.  The time course of vertigo is also important.  Episodic true vertigo that lasts for seconds and is associated with head or body position changes is probably due to benign paroxysmal positional vertigo (BPPV).  Vertigo that lasts for hours or days is probably caused by Ménière disease or vestibular neuronitis.  Vertigo of sudden onset that lasts for minutes can be due to brain or vascular disease, especially if cerebrovascular risk factors are present.

Central vertigo secondary to brainstem or cerebellar ischemia is often associated with other brainstem characteristics, including diplopia, autonomic symptoms, nausea, dysarthria, dysphagia, or focal weakness.  Patients with cerebellar disease are frequently unable to ambulate during acute episodes of vertigo.  Patients with peripheral vertigo can usually ambulate during episodes and are consciously aware of their environment.

A history of headaches, especially migraine headaches, can be associated with migraine-related dizziness.  Previous viral illness, cold sores, or sensory changes in the cervical C2-C3 or trigeminal distributions usually indicate vestibular neuronitis or recurrent episodes of Ménière disease.

Dysdiadochokinesis and gait ataxia during episodes are more likely due to cerebellar diseases, especially in the elderly population.  Sensory and motor symptoms and signs are usually associated with CNS diseases.  The history should include a review of systems (especially head trauma and/or ear diseases) and screening for anxiety and/or depression.  History of prescription medicines, over-the-counter medications, herbal medicines, and recreational drugs (including smoking and alcohol) can help to identify pharmacologically induced syndromes.

The most common causes of peripheral vertigo include BPPV, vestibular neuronitis, Ménière disease, and immune-mediated inner-ear disease.  The most common cause of central dizziness is migraine, frequently referred to as vestibular migraine or migraine-associated dizziness.  Other central causes include demyelination, acoustic tumors, or cerebellar lesions.





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