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LESSON 152

Dizziness: history first

Year 2
Spring semester
Vestibular Assessment I
Vestibular assessment
Duration: 9:52

We explain how to tell vertigo, presyncope and disequilibrium apart in a patient who complains of dizziness, the current approach based on timing and triggers, and the red flags that need urgent referral. We also cover the history patterns of common vestibular disorders and the Dizziness Handicap Inventory.

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Hello, and welcome to the AIHEAR Audiology Academy.
In this lesson, we learn how to approach a patient who complains of dizziness by taking a history.
We will cover the types of symptoms, classification by timing and triggers, and the findings that need urgent referral.
Dizziness is one of the most common reasons for visits to primary care and the emergency department.
Its causes range very widely, from the inner ear to the brain, and from the heart to medications.
Tests matter, but without asking the right questions, it is not possible to choose the right test.
In many vestibular disorders, a well-taken history largely sets the direction of the assessment.
This is why vestibular assessment always begins with the history.
Patients use the word dizziness for very different sensations.
Vertigo, a spinning sensation, is the illusion that oneself or the surroundings are moving when no movement is taking place.
Presyncope, the feeling of being about to faint, involves dimming vision and near fainting; it is often circulatory.
Disequilibrium is unsteadiness felt not in the head but when standing and walking.
There is also a hard-to-describe feeling, such as a hollow or woozy head; this is called nonspecific dizziness.
This distinction is a useful guide, but patients cannot always describe the sensation clearly.
The classic approach was to look for a cause based on the type of sensation the patient described.
However, studies have shown that patients can describe the same sensation with different words at different times.
For example, a serious cause such as stroke may be described as lightheadedness rather than spinning.
So the current approach focuses on timing and triggers rather than the type of sensation.
From the initials of its English name, this approach is also known as TiTrATE.
By timing and triggers, dizziness can be divided into four main groups.
In acute vestibular syndrome, dizziness starts suddenly and continues for days; vestibular neuritis is a typical example.
In triggered episodes, a specific action starts the symptom, as in positional vertigo or a blood pressure drop on standing.
Spontaneous episodes start without a clear trigger; Meniere's disease and vestibular migraine are in this group.
Chronic dizziness lasts for months; bilateral vestibular loss and persistent postural-perceptual dizziness are examples.
This grouping quickly narrows the possible causes and decides which tests to choose.
How long the attacks last is one of the most valuable questions in the history.
Attacks that last seconds and start with head movement suggest benign paroxysmal positional vertigo, or BPPV.
Attacks lasting minutes to hours suggest vestibular migraine and, rarely, transient disorders of brain circulation.
Attacks lasting twenty minutes to twelve hours, with ear symptoms, suggest Meniere's disease.
A single severe attack lasting days should bring to mind vestibular neuritis, but also stroke.
When asking about duration, help the patient separate the worst spinning from the lightheadedness that remains afterward.
Covering the history topics in a systematic order makes the job easier.
When and how did the first attack start, and how has it gone since then?
Is there hearing loss, tinnitus or aural fullness, and in which ear?
Is there a history of migraine, or headache, light and sound sensitivity with the attacks?
Medications are reviewed, especially blood pressure medications and sedatives.
Falls, injuries and how much daily life is affected are also recorded.
Starting the history with an open-ended question lets patients describe their experience in their own words.
Leading questions such as "Is the room spinning?" can unintentionally shape the answer.
Asking patients to describe their last attack from start to finish, hour by hour, often gives the clearest information.
Observations from a companion who was present during an attack are valuable, especially with fainting and falls.
Patients with infrequent attacks can be offered a diary to note the date, duration and accompanying symptoms.
Some findings suggest that there may be an urgent cause behind the dizziness.
A new, severe headache or neck pain is one of them.
Double vision, trouble speaking or swallowing, and numbness or weakness in the face or arm are urgent signs.
Being unable to stand or walk, even with help, is also a serious finding.
Acute dizziness that starts together with sudden hearing loss may be due to blockage of the artery supplying the inner ear.
If chest pain, palpitations or fainting accompany it, cardiac causes are considered.
A clinical tip: if any red flag is present, do not try to complete the planned test battery.
Refer the patient for urgent medical evaluation without delay.
Record the time the symptoms began and the findings you observed, briefly and clearly; this is valuable for the emergency team.
When in doubt, referring is always safer than waiting.
The histories of common conditions often follow familiar patterns.
Spinning that starts when turning in bed and lasts less than a minute is the typical history of BPPV.
Spinning that lasts hours and comes with aural fullness and roaring tinnitus suggests Meniere's disease.
Recurrent attacks in a person with a migraine history who is bothered by light and sound during attacks suggest vestibular migraine.
Severe spinning that starts one morning and lasts days, without hearing loss, fits vestibular neuritis.
These patterns are guides; the definitive diagnosis is made by the physician's evaluation and the test findings.
Anxiety is common in people with dizziness, and anxiety can also make dizziness worse.
Avoiding movement and going out for fear of an attack can help keep the symptoms going.
In chronic dizziness, crowded places and moving visual scenes often make symptoms worse.
These symptoms are not imaginary; taking the patient's complaint seriously is the basis of trust.
If needed, the patient is referred to the appropriate specialists through the physician.
Alongside the history, questionnaires are used to measure the effect of dizziness on daily life.
The most widely used is the Dizziness Handicap Inventory, or DHI.
The DHI has twenty five items and is scored from zero to one hundred; a higher score means greater handicap.
A Turkish adaptation of the scale and validation studies have also been published.
Questionnaires do not make a diagnosis, but they are valuable for monitoring and for seeing the effect of rehabilitation.
Once the history is complete, a working assessment emerges that sets the next steps.
If there is a red flag, urgent referral comes first.
The history sets the likely group; for example, positional tests stand out for triggered positional attacks.
In every case, the bedside exam is the first physical assessment that completes the history; we will see it in the next lesson.
Then, for spontaneous attacks, hearing tests and a vestibular test battery are planned.
Dizziness can be vertigo, presyncope, disequilibrium or a nonspecific feeling.
The current approach focuses on timing and triggers rather than the type of sensation.
Attack duration is a strong clue for telling apart conditions such as BPPV, migraine, Meniere's disease and neuritis.
Neurological symptoms, a severe headache or being unable to stand require urgent referral.
Test yourself: In vertigo that starts suddenly and lasts for days, what must be considered besides vestibular neuritis?
The correct answer is B: stroke.
This is why neurological symptoms are asked about carefully, and when in doubt, the patient is referred to an emergency physician.
In the next lesson, we will learn the bedside vestibular exam: the Romberg, Fukuda and head-shaking tests.
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