How to differentiate between dizziness and vertigo (benign paroxysmal positional vertigo) in a patient?

From the Guidelines

To differentiate between dizziness and vertigo, ask the patient to describe exactly what they're feeling, focusing on whether they experience a spinning or rotating sensation, and inquire about the onset, duration, and triggers of their symptoms, as well as any associated symptoms like nausea or hearing changes, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1. When exploring a patient's symptoms to determine if they are experiencing dizziness or vertigo, it is crucial to understand the definitions and distinctions between these two conditions.

• Vertigo is defined as an illusory sensation of motion of either the self or the surroundings in the absence of true motion, often described as a spinning or rotating sensation.
• Dizziness, on the other hand, is a broader term that encompasses a range of sensations including lightheadedness, faintness, unsteadiness, or a feeling of being off-balance. The patient's description of their symptoms is vital in making this distinction.
• For dizziness, ask if they feel lightheaded, faint, unsteady, or off-balance.
• For vertigo, specifically inquire if they experience a spinning or rotating sensation, either of themselves or their surroundings. It is also important to ask about the onset (sudden or gradual), duration (seconds, minutes, hours), and triggers (position changes, head movements) of their symptoms.
• Determine if symptoms worsen with certain movements or positions, particularly when lying down or looking up.
• Inquire about associated symptoms like nausea, vomiting, hearing changes, tinnitus, or ear fullness, which often accompany vertigo.
• Ask about recent illnesses, medications, and history of similar episodes. The distinction between dizziness and vertigo matters because vertigo typically indicates an inner ear or vestibular pathway problem (like BPPV, Meniere's disease, or vestibular neuritis), while dizziness may suggest cardiovascular issues, medication effects, anxiety, or metabolic disorders. This differentiation guides appropriate treatment, whether it's vestibular rehabilitation exercises for vertigo or addressing underlying causes for dizziness. Having the patient demonstrate how they would explain their sensation to someone else can be particularly revealing in making this important clinical distinction. Given the complexity and variability of vestibular disorders, a thorough and detailed patient history is essential for accurate diagnosis and effective management, as emphasized in clinical practice guidelines for benign paroxysmal positional vertigo (BPPV) and other vestibular conditions 1.

From the Research

Differentiating between Dizziness and Vertigo

To explore whether a patient's symptom is representing dizziness or vertigo, it is essential to ask specific questions that can help differentiate between the two. The following are some key points to consider:

• Dizziness is a common yet imprecise symptom that can be divided into four categories: vertigo, presyncope, disequilibrium, and light-headedness 2.
• Vertigo is a type of dizziness characterized by a sensation of spinning or rotation, and it can be further classified into peripheral and central etiologies 2, 3.
• Patients with vertigo often experience symptoms triggered by head motion, and the timing and triggers of the symptoms can be crucial in determining the underlying cause 2, 4.

Questions to Ask

Some questions that can be asked to differentiate between dizziness and vertigo include:

• Can you describe the sensation you are experiencing? Is it a spinning sensation, a feeling of being off-balance, or something else?
• What triggers your symptoms? Are they triggered by head motion, changes in position, or other factors?
• How long do your symptoms last? Are they episodic or continuous?
• Do you experience any other symptoms, such as hearing loss, tinnitus, or nausea, in association with your dizziness or vertigo?
• Have you experienced any recent head trauma, ear infections, or other medical conditions that could be contributing to your symptoms?

Physical Examination and Diagnostic Tests

A physical examination, including orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver, can help determine the underlying cause of vertigo 2, 4.

• The HINTS (head-impulse, nystagmus, test of skew) examination can help distinguish peripheral from central etiologies of vertigo 2.
• The Dix-Hallpike test is a positioning nystagmus test used for diagnosis of posterior-canal-type benign paroxysmal positional vertigo (BPPV) 4.
• The head roll test is a positional nystagmus test used for diagnosis of lateral-canal-type BPPV 4.