How do you differentiate vertigo from dizziness?

Distinguishing Vertigo from Dizziness

Vertigo is specifically defined as a false sensation of self-motion or environmental motion (typically spinning), while dizziness is a broader term referring to disturbed or impaired spatial orientation without a false sense of motion. 1

Key Differences Between Vertigo and Dizziness

Definition and Sensation

• Vertigo: A specific illusion of rotation or spinning (either of self or surroundings)
• Dizziness: A general sense of spatial disorientation without rotational component

Clinical Description

Patients with true vertigo will typically:

• Describe a sensation of "spinning" or "room spinning"
• Often use hand gestures indicating rotation
• Report worsening with head movements
• Experience associated nausea/vomiting

Patients with non-vertiginous dizziness may describe:

• Lightheadedness
• Feeling "off balance"
• Floating sensation
• Wooziness
• Feeling disconnected

Diagnostic Approach

1. Focus on Timing and Triggers (Rather Than Symptom Quality)

• Acute Vestibular Syndrome: Sudden, persistent vertigo lasting days
• Spontaneous Episodic Vestibular Syndrome: Recurrent vertigo without clear triggers
• Triggered Episodic Vestibular Syndrome: Vertigo provoked by specific positions/movements 2

2. Key Questions to Ask

• "Do you feel like you or the room is spinning?" (vertigo)
• "Do you feel like you might pass out?" (presyncope/dizziness)
• "Do you feel unsteady on your feet?" (disequilibrium/dizziness)
• "What triggers the symptoms?" (positional changes, specific movements)
• "How long do episodes last?" (seconds, minutes, hours, days)
• "Are there associated symptoms?" (hearing loss, tinnitus, headache, neurological symptoms)

3. Physical Examination Elements

• HINTS examination (Head-Impulse, Nystagmus, Test of Skew) - crucial for distinguishing peripheral from central causes of vertigo 1
• Dix-Hallpike maneuver - specific for diagnosing BPPV 1
• Observation of nystagmus - direction, duration, and triggers provide diagnostic clues
• Complete neurological examination - to identify central causes

Common Causes of Vertigo vs. Dizziness

Vertigo (Usually Rotational)

1. Peripheral Causes (inner ear):

   • Benign Paroxysmal Positional Vertigo (BPPV) - brief episodes triggered by head position changes
   • Vestibular neuritis - acute, prolonged vertigo without hearing loss
   • Ménière's disease - episodic vertigo with fluctuating hearing loss, tinnitus, aural fullness
   • Labyrinthitis - vertigo with hearing loss

2. Central Causes (brain):

   • Vestibular migraine - vertigo episodes with migraine history
   • Stroke/TIA affecting posterior circulation
   • Multiple sclerosis
   • Cerebellar/brainstem tumors

Dizziness (Usually Non-rotational)

1. Cardiovascular causes:

   • Orthostatic hypotension
   • Cardiac arrhythmias
   • Vasovagal syncope

2. Metabolic/Systemic causes:

   • Hypoglycemia
   • Anemia
   • Medication side effects

3. Psychological causes:

   • Anxiety disorders
   • Panic attacks
   • Depression

Red Flags Suggesting Central Causes

• Neurological symptoms (diplopia, dysarthria, dysphagia, numbness)
• Severe headache or neck pain
• New-onset vertical or direction-changing nystagmus
• Inability to stand or walk
• Abnormal HINTS examination

Common Pitfalls to Avoid

1. Relying solely on symptom quality - The traditional approach of categorizing based on symptom description (vertigo vs. dizziness) is less reliable than focusing on timing and triggers 2

2. Missing stroke in acute vertigo - Up to 25% of patients with acute vestibular syndrome have a stroke, and many lack obvious neurological signs 1

3. Overusing imaging - Not all dizzy patients need CT/MRI; clinical examination (especially HINTS) can be more sensitive than early MRI for stroke detection 1

4. Confusing vestibular migraine with Ménière's disease - In migraine, "hearing loss" may be a perception of difficulty processing sound rather than actual hearing loss, and symptoms are often bilateral 1

5. Failing to recognize BPPV - This common cause of vertigo is often missed but easily diagnosed with the Dix-Hallpike maneuver and treated with repositioning maneuvers 1

By carefully distinguishing between true vertigo and other forms of dizziness through focused history-taking and targeted physical examination, clinicians can more accurately diagnose the underlying cause and provide appropriate treatment, ultimately improving patient outcomes.