The Ten-Minute Examination of the Dizzy Patient

, Department of Otolaryngology, Division of Head and Neck Surgery, Washington University School of Medicine, Saint Louis, Missouri.

Semin Neurol. 2001;21(4) 

In This Article

The Dizziness Questionnaire and Patient Interview

Prior to the arrival of the patient in the office, the dizziness questionnaire is mailed to the patient's home to be filled out in detail and returned before the visit (Fig. 1). This questionnaire is divided into five main sections:


  1. Description of the spell

  2. Accompanying symptoms indicative of peripheral etiology

  3. Accompanying symptoms indicative of central etiology

  4. Accompanying auditory complaints

  5. General physical and emotional health


For easy identification, "yes" and "no" options are placed in the left and right margins, respectively, and circled.

Description of the Spell

The hallmark of peripheral dizziness is the definite sensation of relative motion with the visual world, namely vertigo. The sensation is usually described by patients as a "spinning" or "whirling" feeling or the notion that they or their surroundings are moving in a circular fashion. In this first section of the questionnaire, the patient is asked to describe his or her sensation without using the word "dizziness." For most patients with peripheral labyrinthine disorders, the description is brief and very focused on vertigo. Patients with acute central nervous system (CNS) dysfunction may or may not have sensations of vertigo, whereas chronic CNS, cerebrovascular, cardiovascular, and metabolic causes of dizziness seldom produce true sensations of relative motion.

Symptoms Accompanying Peripheral Disease

Patients with peripheral vertigo have distinctive features of onset, duration, and accompanying symptoms in relation to their dizziness. Peripheral vertigo comes in spells and usually lasts seconds (benign positional vertigo), minutes (Ménière's disease), or hours (vestibular neuritis). Hearing loss, tinnitus, and aural fullness are frequent symptoms of peripheral disease. Position changes exacerbate the dizziness, and lying still lessens the symptoms. Benign positional vertigo, for instance, is highly suspected in cases of brief vertigo brought on by a simple position change such as rolling over in bed. In most attacks, the onset is sudden although the offset is less well defined. For the most part, patients feel fine between spells.

Symptoms Accompanying Central Nervous System Disease

Unlike peripheral vertigo, central causes of dizziness produce a more variable picture. The sensation may be described in a variety of ways: spinning, tilting, pushed to one side, lightheadedness, clumsiness, or even blacking out. If documented loss of consciousness is present, a peripheral etiology of the dizziness is rarely if ever at fault. Also helpful for localization is the presence of accompanying signs of neural dysfunction, that is, dysarthria, dysphagia, diplopia, hemiparesis, severe localized cephalgia, seizures, and memory loss. The time course of symptoms is more variable from minutes to hours, and the effect of movement or position change is less predictable. These symptoms lead the clinician to suspect brain stem or cortical rather than labyrinthine sources.

Accompanying Auditory Complaints

The single most useful localizing symptom in a dizzy patient is a unilateral otologic complaint: aural fullness, tinnitus, hearing loss, or distortion. By carefully evaluating these complaints, the clinician frequently can localize both the side and the site of the lesion before any examination or testing is done. Frequent causes of unilateral auditory disease with dizziness include endolymphatic hydrops, perilymphatic fistula, labyrinthitis, vestibular neuritis (slight high-pitched loss with tinnitus), and autoimmune inner ear disease.

General Physical and Emotional Health

Many medical conditions and emotional factors can create a sense of dizziness and imbalance. Hypertension, hypotension, atherosclerotic disease, endocrine imbalances, and anxiety states are common causes of lightheadedness, near syncope, and/or instability but rarely produce a sense of true vertigo. In addition, medication side effects and excessive caffeine, nicotine, and alcohol intake should be investigated as a source of dizziness. Ideally, these conditions have already been addressed by the patient's primary care physician before a referral for formal evaluation by a neurotologist or neurologist.

For further details on history taking in the dizzy patient, the reader is referred to the reviews listed in the reference section.[1,2,3,4]