Symptom: Dizziness

TRIAGE QUESTIONS

Question 1: Is the dizzy sensation actually vertigo?

  • Vertigo is the hallucination of movement: the room spins or the bed rises and falls etc. when in fact you are still

  • Vertigo can be a symptom of the vestibular system but it can also be a central nervous symptom

  • Dizziness, lightheadedness, giddiness, 'feeling wrapped in cotton wool' are usually symptoms of the central nervous system

  • Dizziness can be a symptom of cardiac problems, stroke, TIA, polypharmacy, alcohol intake etc.

  • Yes - Go to question 2

  • No - Refer patient for general medical or neurological management

 

Question 2: How long does the vertigo last and what brings it on?

  • Episodic, lasts seconds, usually on turning head a particular way or turning over in bed: might be benign paroxysmal positional vertigo (BPPV)

  • Episodic, lasts minutes to hours, sometimes aggravated on standing, no focal neurology or postural hypotension etc., associated with increased age: might be a type of generalised age-related dysequilibrium

  • Episodic, warning aura, headache, photophobia, post-headache 'fuzziness', lasts a few hours to one day: might be vestibular (or vertiginous) migraine

  • Episodic, without warning, typically unilateral hearing loss, tinnitus and sensation of aural pressure, lasts a few hours, commonly in 40-60 year olds: might be Ménière's disease; if no aural pressure, then rarely it might be a bleed inside an acoustic neuroma

  • Constant, lasts days or longer, reduction in mobility, vomiting etc.: might be some sort of labyrinthine disorder/viral infection, commonly labelled as 'labyrinthitis'

Remember that a stroke can give you vertigo: when in doubt, rule out the more serious pathology first.  

 

Question 3: Is the patient unwell, unable to mobilise safely or vomiting, or is there any focal neurology etc.? 

  • Yes - Refer patient for general medical or neurological management

  • No - Go to Question 4

 

Question 4: Do you think this is BPPV, Ménière's, an acoustic neuroma etc.?

  • Yes - Refer patient to ENT clinic; a fuller assessment of the vestibulocochlear system can be made in clinic as there is access to balance specialists, vestibular testing and audiology

  • No - It may still be safer to refer the patient for a general medical assessment to rule out an atypical presentation of a neurological or cardiological problem

Consider prescribing a very limited course (eg one week) of vestibular sedatives such as cinnarizine or prochlorperazine for symptomatic control. Betahistine is a medication specific to Ménière's disease, is not a panacea for vertigo and should only be used after a full balance assessment, including audiology. 

Remember that a stroke can present with new vertigo: when in doubt, rule out the more serious pathology first. 

 

 

 

Page last reviewed: 1 December 2022