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Approach to patient with Dizziness


  • “Does it feel like either the room is spinning or that you are spinning?” and/or “Is it triggered or worsened by turning your head or rolling over in bed?”

    • Yes = vertigo


        • brief, recurrent episodes (seconds to minutes), +/- nausea and vomiting

      • Vestibular Neuritis

        • rapid onset, severe, persistent (days), N/V, imbalance

      • Ménière’s Disease

        • recurrent episodes (minutes to hours), fluctuating hearing loss, tinnitus, and sensation of aural fullness

      • Vestibular Toxicity

        • aminoglycosides (eg. gentamycin), loop diuretics, ASA, NSAIDs, amiodarone, quinine, cisplatin

    • No = other forms of dizziness

      • Presyncopal Dizziness – “feels like nearly fainting or blacking out”

        • ECG

        • Triggered by exertion? Chest pain/palpitations? Known structural heart dz? FmHx of sudden death? Abnormal ECG? (if pt stable, fax ECG for urgent advice)

          • If yes to any, suspect cardiac etiology. Refer to Emergency

          • If no, orthostatic hypotension?

            • Yes = investigate underlying cause. meds/alcohol? Consider CBC/lytes

            • No = likely vasovagal/situational etiology. If recurrent episodes or pt is at risk of injury, consider referral for tilt test (+/- carotid sinus massage if >40 yo)

      • Disequilibrium Dizziness – “unsteadiness while walking”

        • Often multifactorial, common in elderly, risk of falls. Complete neuro and MSK exams to rule out peripheral neuropathy, Parkinsonism, MSK d/o, CVA, etc

      • Nonspecific Dizziness – “woozy”, “giddy”, “light-headed”

        • DDx: hypoglycemic (glucose), thyroid disease (TSH), pregnancy (β-HCG), meds, psychiatric disorders, alcohol/drugs, menstruation, previous head trauma

  • Ask about: onset, duration, nausea, vomiting, hearing loss, tinnitus, headache, imbalance, aural fullness, ear pain, rash, facial paralysis, medications



  • viral labyrinthitis

  • benign positional vertigo

  • Eustachian tube dysfunction (often with serous otitis media)

  • Meniere's disease

  • Vertebrobasilar insufficiency (in the elderly with vasculopathy)


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