Introduction

All too often the patient presents to the doctor complaining of ‘dizziness’, which is a ‘non-word’ as it is ambiguous and means different things to different people. ‘Dizziness’ can mean ‘true vertigo’ but it can also mean confusion, tiredness, light-headedness, loss of balance, headache, hunger or any other variety of words idiosyncratic to any particular patient. It follows that there can be no correct approach until the definition relevant to that patient has been established.

Patients will often get angry when asked to define ‘dizziness’ and, all too often, the doctor will accept ‘dizziness’ to mean something different to what the patient is trying to report. The doctor will translate ‘dizziness’ to mean ‘vertigo’ when in many cases it does not. As with all neurology, it is the history that is so important. The word ‘giddy’ is not a substitute for ‘dizzy’, and likewise is ambiguous and a ‘non-word’ meaning different things to different people.

Vertigo is a very specific word derived from two words, namely ‘vertere’, to turn and ‘igo’, a condition.¹ It implies an unreal sensation of motion, meaning that the patient perceives the sensation of movement when, in fact, the patient is stationary. Thus history taking when exploring what might prove to be true vertigo must explore the question of unreal motion, which can be objective, implying the external environment is perceived as moving, or subjective, in which the patient feels as if they are moving while the surroundings are stationary. Both equate to vertigo.

Perhaps the most common cause for vertigo to be referred to a neurologist is that of benign positional paroxysmal vertigo (BPPV), which can and should be successfully treated by the family doctor, although more often than not it does result in referral to either a neurologist or ear, nose and throat (ENT) surgeon.

What follows is a discussion of vertigo that will allow the general practitioner to take control in most instances. It aims to demystify vertigo and empower the general practitioner.

Taking the History

The most important part of history taking has already been discussed. It is absolutely imperative for both patient and doctor to read from the same text. Message sent must equate to message received. Causes for loss of balance can be quite different to those for vertigo. Differentiation will dictate appropriate management, namely diagnosis and its treatment.

Having confirmed that the basis for presentation is vertigo, the doctor needs to clarify its cause. The type and nature of the vertigo will help with diagnosis. Vertigo that occurs in bed, particularly after turning over in bed either right to left (or the converse), is more likely than not, going to be BPPV (see Table 8.1). Vertigo that follows an upper respiratory tract infection will probably be caused by labyrinthitis or vestibular neuronitis (see Table 8.1). Vestibular neuronitis (labyrinthitis) is usually of acute or subacute onset, causing rotatory vertigo together with nausea and postural loss of balance.

TABLE 8.1 Peripheral causes of vertigo

Vertigo associated with profound vomiting and deafness may be a case of Ménière’s disease (see Table 8.1). Ménière’s disease often has a greater problem with tinnitus, which may precede the complaint of loss of hearing. Other peripheral causes of vertigo are fairly rare (see Table 8.1).²

When considering vertigo, one should not overlook motion-induced vertigo that may relate to either peripheral vestibulitis or BPPV. Psychogenic causes of vertigo, as are reported in the patient who claims seasickness even when watching the ocean from dry land, may need desensitising and referral is warranted. Psychogenic vertigo may also occur in conjunction with panic disorders or hyperventilation.

There are also central causes of vertigo (Table 8.2),³ acknowledging that vertigo may be provoked by dysfunction anywhere along the vestibulo-cochlear pathway. This travels from the receptors in the ears, which record motion and position within the environment, and travel along the 8th cranial nerve to the pontine, brainstem connections. Hearing is also dependent upon competence of the 8th cranial nerve and, with mutual passage, both can be ‘interrupted’ by common aetiologies.

TABLE 8.2 Central causes of vertigo