Vertigo and Dizziness

🔍 When to Suspect

A false sensation of movement (most commonly spinning), requiring careful history to determine timing, triggers, and associated symptoms

From the full topic in The Ocean Library: Vertigo and Dizziness

🧭 When to suspect (vertigo vs light-headedness)

The first decision is what the patient actually means by “dizzy”. Separate:

• True vertigo: a false sensation of movement – spinning, tilting, rocking.

• Presyncope/light-headedness: a feeling of being about to faint, which points towards cardiovascular or orthostatic causes.

• Disequilibrium: unsteadiness on the feet without illusory movement.

Vertigo localises the problem to the vestibular system – the inner ear or its central connections.

Once vertigo is established, do not rely on the old question “what does the dizziness feel like?”.

• It is more reliable to categorise by timing and triggers, which points to the likely diagnosis and the most useful bedside test.

The two skills that matter in primary care:

• To treat the common, benign causes within the consultation.

• To never miss a central cause – above all a posterior circulation stroke presenting as acute vestibular syndrome (sudden, continuous vertigo lasting more than 24 hours).

Pattern (timing & trigger)	Think of	Key bedside test
Acute vestibular syndrome – sudden, continuous vertigo lasting days	Vestibular neuritis vs posterior circulation stroke	Head impulse, nystagmus, test of skew (HINTS) (only if spontaneous nystagmus is present)
Triggered, brief, positional – seconds, on head movement or rolling over in bed	• Benign paroxysmal positional vertigo (BPPV) (the commonest cause overall) • Orthostatic hypotension	Dix–Hallpike (and lying/standing BP)
Spontaneous, episodic – minutes to hours, recurrent	Vestibular migraine (commonest recurrent cause), Ménière’s disease, TIA	History ± audiometry if aural symptoms

Raise concern for a central cause in anyone with:

• Vascular risk factors (age, smoking, hypertension, diabetes, atrial fibrillation).

• A new headache or neck pain.

• Any focal neurology.

• Severe truncal ataxia.

Vestibular migraine is “central” in origin but benign; the dangerous central cause to exclude is stroke.

Source: NICE NG127 · BMJ Practice (Acute vertigo, 2019)

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