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Dizziness and Vertigo: History Taking and Differential Diagnoses

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Overview

Vertigo describes the sensation of movement of themselves or their surroundings when they are not, often described as ‘the room spinning’ or the patient ‘swaying’.

Dysfunction of the vestibular pathway leads to vertigo. Vertigo can be classified as peripheral or central depending on which part of the vestibular pathway is affected. It is essential to ascertain what type of vertigo is present, as it may be presenting feature of a serious underlying cause including stroke.

“Dizziness” may be used to describe:

  • Light-headedness – the feeling as if the patient is about to faint or “pass out”
  • Vertigo – the feeling of movement or the environment moving around the patient when they are not moving

This is where the head impulse, nystagmus, and test of skew (HINTS) examination is useful.

Causes

Vestibular causes

  1. Benign paroxysmal positional vertigo (BPPV) – the most common cause
  2. Ménière’s disease
  3. Vestibular neuronitis
  4. Labyrinthitis
  5. Cholesteatoma

Neurological causes

Other causes

History Taking

All symptoms

With each presenting complaint, explode the symptom:

  • When did it start?
  • Sudden or gradual?
  • Continuous or intermittent?
  • One or both ears?
  • Has this ever happened before?

Vertigo

  • Onset:
    • When did it start?
    • Sudden or gradual?
  • Timeline:
    • Continuous or intermittent?
    • Duration – seconds/minutes/hours?
    • Frequency – does it happen in episodes?
  • Associated symptoms:
    • Auditory symptoms – tinnitus/deafness/aural fullness
    • Neurological symptoms – weakness, visual changes, ataxia, visual changes, headaches, photophobia
  • Are there any triggers?
    • Is it triggered by head movements?
    • Is it triggered by standing up from sitting?

Red flags

Signs and symptoms of a central cause (which can be caused by stroke, multiple sclerosis, brain tumours etc.) can be remembered as the 5 dangerous Ds:

External ear

  • Has there been any trauma to the ear?
  • Has anything been put into the ear?

Middle ear

  • Any ear discharge?
    • Is it blood, purulent, or clear?
  • Any ear “popping”?

Inner ear

  • Is there tinnitus? – is there any ringing or humming?
  • Is there any vertigo? – are they dizzy? Is the room spinning?

Review of systems

Screen for general red flags:

  • Any fever?
  • Any night sweats?
  • Any unexplained weight loss?
  • Any symptoms associated with a stroke? Examples are:
    • Problems with balance?
    • Problems with speech?
    • Weakness or numbness?

Screen for ear symptoms:

  • Tinnitus?
  • Dizziness? – does the room spin?
  • Ear pains?
    • Use SOCRATES
  • Ear discharge?
  • Do they hear any clicking or popping?
  • Do their ears ever feel full?
  • Has anything been inserted into the ear?

Screen for nose symptoms:

Screen for throat symptoms:

Screen for neurological symptoms:

Screen for syncope and pre-syncope?

  • Are there any triggers such as passing urine, exercise, stress, seeing something unpleasant, or standing up from sitting?
  • Nausea/vomiting?
  • Sweating?
  • Pallor?
  • Chest pain

Past Medical History

Questions include:

  • Do they have any other medical conditions?
  • Have they ever had any previous surgery?
  • Do they take any regular medications?
  • Do they take any over-the-counter medications, herbal remedies, or supplements?
  • Have they had a recent infection such as a cold or the flu?
  • Do they take eardrops? – some patients forget these count as regular medications

Family History

  • Is there any family history of anything similar?

Allergy History

  • Are they allergic to anything?
    • What happens during the allergic reaction?

Social History

  • Do they smoke?
    • If so, how much and how long?
  • Do they drink alcohol?
    • If so, how much and how long?
  • Do they use any illicit drugs?
    • If so, how much and how long?
  • What is their occupation?
  • Who’s at home?
    • What support do they have?
  • How has this impacted their activities of daily living?
  • Has there been any recent foreign travel?

Physical Examinations

Overview

An ear examination and cranial nerve exam should be performed, including using Weber and Rinne tuning fork tests. Some signs that may be present include:

  • Otoscopy may show:
    • Impacted earwax
    • External ear canal erythema
    • Cholesteatoma
    • Problems with the tympanic membrane (e.g. erythema, perforation, or effusion)
  • Arterial bruits (e.g. carotid bruit) which may suggest a cause of objective tinnitus
  • Weber and Rinne tests may help with identifying the type of any hearing loss present
  • A vestibular schwannoma may lead to cranial nerve involvement:
    • Vestibulocochlear nerve (CN VIII) – hearing loss, tinnitus, and vertigo
    • Trigeminal nerve (CN V) – absent corneal reflex, facial numbness
    • Facial nerve (CN VII) – facial nerve palsy
  • Head impulse, nystagmus, test of skew (HINTS) exam
    • Differentiates between peripheral (e.g. vestibular neuronitis) and central (e.g. stroke) causes of vertigo
  • Eye examination:
    • May show ophthalmoplegia/nystagmus
    • May show papilloedema in increased intracranial pressure
  • Dix-Hallpike manoeuvre:
    • For benign paroxysmal positional vertigo (BPPV)

Investigations

  • Blood glucose:
    • If stroke is suspected, to screen for hypoglycaemia which can mimic a stroke
  • ECG:
    • If a cardiac cause of dizziness is suspected
  • Echocardiography:
    • For cardiogenic syncope
  • Tilt-table testing:
    • For postural hypotension
  • CT head:
    • If stroke suspected
  • Pure tone audiogram:
    • To characterise any hearing loss
  • MRI of the cerebellopontine angle:
    • If vestibular schwannoma suspected
  • Lumbar puncture and cerebrospinal fluid measurement:
    • Increased in idiopathic intracranial hypertension

Differential Diagnoses: Vestibular Causes

Benign positional paroxysmal vertigo (BPPV)

  • A history may reveal:
    • Usually seen in older patients (>50 years)
    • Vertigo triggered by changes in head position, such as rolling over in bed or gazing upwards
    • Vertigo lasts around 10-20 seconds
  • A physical exam may reveal:
    • Dix-Hallpike test is diagnostic – shows rotatory nystagmus that lasts around 30 seconds

Ménière’s disease

  • A history may reveal:
    • 15-minute to 24-hour episodes of vertigo, tinnitus, hearing loss, and aural fullness
    • Aural fullness may precede the attack
  • Investigations may reveal:
    • Diagnosis is clinical
    • Audiometry – unilateral sensorineural hearing loss

Vestibular neuronitis

  • A history may reveal:
    • Acute vertigo with nausea and vomiting without hearing loss or tinnitus
    • Symptoms are worsened with changes in head position
    • There may be a history of a recent upper respiratory tract infection
  • Diagnosis is generally clinical

Labyrinthitis

  • A history may reveal:
    • Acute vertigo that is worsened by movement, nausea, and vomiting
    • There may be associated tinnitus
    • A history of a recent upper respiratory tract infection
  • Diagnosis is mainly clinical

Vestibular migraine

  • A history may reveal:
    • Episodes lasting 4-72 hours with associated headaches, photophobia, or preceding aura
    • There may be associated nausea
  • A physical exam may reveal:
    • Positional nystagmus (nystagmus triggered by changes in head position) and a positive Romberg sign in an acute attack

Cholesteatoma

  • A history may reveal:
    • Foul-smelling persistent discharge
    • There may be associated tinnitus and ear pain
  • A physical exam may reveal:
    • Crusting/pus/debris in the attic (upper part of the middle ear) on otoscopy
  • Investigations may reveal:
    • Pure tone audiogram – shows conductive hearing loss
    • CT petrous temporal bone – confirms the diagnosis
    • MRI – considered if soft tissue involvement suspected

Differential Diagnoses: Neurological Causes

Multiple sclerosis

  • A history may reveal:
    • A history of optic neuritis, fatigue, sensory disturbances (e.g. pins and needles or numbness), spasticity, urinary dysfunction
    • Tinnitus may occur in the absence of hearing loss
  • Investigations may reveal:
    • MRI of the brain and spinal cord with gadolinium contrast – shows white matter lesions

Vestibular schwannoma (acoustic neuroma)

  • A history may reveal:
    • Hearing loss, tinnitus, vertigo
    • Cranial nerve involvement (e.g. the trigeminal nerve and facial numbness)
    • May present with sudden sensorineural hearing loss (<72 hours)
  • A physical exam may reveal:
    • Signs of trigeminal nerve (CN V) or facial nerve (CN VII) palsy
  • Investigations may reveal:
    • MRI of the cerebellopontine angle – investigation of choice
    • Audiometry – helps determine the degree of hearing loss

Posterior circulation stroke

  • A history may reveal:
    • Acute vertigo with dysarthria, weakness, headaches, double vision
  • A physical exam may reveal:
    • HINTS test may show a normal head impulse, vertical/bidirectional nystagmus, and skew deviation
    • Hemiparesis, hemisensory losses, aphasia, ataxia, nystagmus
  • Investigations may reveal:
    • Blood glucose – to screen for hypoglycaemia which can mimic a stroke
    • Non-contrast CT brain – to screen for haemorrhagic stroke

Vertebrobasilar insufficiency

  • A history may reveal:
    • Usually more common in older patients
    • Episodic vertigo lasting 30 seconds to 15 minutes triggered by extending the neck or turning the head
    • Risk factors for atherosclerotic disease, such as hypertension, hyperlipidaemia, ischaemic heart disease
  • Investigations may reveal:
    • MRI brain and MR angiography – may show infarction and arterial occlusion on angiography

Idiopathic intracranial hypertension

  • A history may reveal:
    • An overweight, white, female patient
    • The use of drugs including tetracyclines or the combined oral contraceptive pill
    • Headaches suggestive of elevated intracranial pressure (e.g. worse in the morning, worse on bending forward)
    • Associated blurred vision
  • A physical exam may reveal:
    • Enlarged blind spot and papilloedema
  • Investigations may reveal:
    • MRI brain – rules out mass lesions
    • Lumbar puncture – increased opening pressure

Differential Diagnoses: Other Causes

Orthostatic hypotension

  • A history may reveal:
  • A physical exam may reveal:
    • Drop in systolic blood pressure by at least 20 mmHg or at least 10 mmHg diastolic within 3 minutes of standing from sitting or lying
  • Investigations may reveal:
    • Tilt-table testing – shows an orthostatic decrease in blood pressure and elicits symptoms

Pre-syncope

  • A history may reveal:
    • Nausea, sweating, pallor, palpitations, headaches, blurred vision
    • There may be a trigger such as exercise, passing urine, or seeing something unpleasant
  • Investigations may reveal:
    • ECG – may identify arrhythmia
    • Holter monitoring – may identify arrhythmia
    • Echocardiogram – may show structural heart disease

Carbon monoxide poisoning

  • A history may reveal:
    • There may be poorly maintained housing (e.g. broken boilers or cookers)
    • Other household members or pets may be ill as well
    • Most cases have an associated headache and there may be confusion
  • Investigations may reveal:
    • Carboxyhaemoglobin – elevated

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