What is the difference between light headedness and dizziness, and how are they managed?

Light-headedness vs. Dizziness: Differentiation and Management

Light-headedness and dizziness are distinct symptoms with different underlying causes, requiring different management approaches. Light-headedness refers to a feeling of faintness or being about to pass out, while true dizziness (vertigo) involves a false sensation of spinning or movement.

Definitions and Differentiation

• Dizziness is a general term that can be categorized into four distinct types 1, 2:

  1. Vertigo: A false sensation of spinning or movement (either of self or surroundings)
  2. Presyncope/Light-headedness: Feeling of impending faint or loss of consciousness
  3. Disequilibrium: Unsteadiness or imbalance without vertigo
  4. Non-specific dizziness/Lightheadedness: Vague sensation that doesn't fit other categories

• Light-headedness (Presyncope) specifically refers to symptoms before potential syncope, including extreme lightheadedness, visual sensations like "tunnel vision" or "graying out", and variable degrees of altered consciousness without complete loss of consciousness 1

• Vertigo is defined by the Barany Society as a false sensation of self-motion and a false sensation that the visual surroundings are spinning or flowing 1

Clinical Differentiation

• Light-headedness/Presyncope:

  • Often associated with orthostatic changes (standing up quickly) 1
  • May be accompanied by palpitations, tremulousness, generalized weakness, blurred vision 1
  • Often related to cardiovascular causes or orthostatic hypotension 1
  • No rotational component or spinning sensation 2

• Vertigo:

  • Characterized by a distinct spinning or rotational sensation 1
  • Often accompanied by nausea, vomiting, and difficulty with balance 1
  • May be triggered by specific head positions or movements 1
  • Often associated with nystagmus (involuntary eye movements) 1, 3

Common Causes

Light-headedness/Presyncope

• Orthostatic hypotension (drop in blood pressure upon standing) 1
• Cardiac arrhythmias or structural heart disease 1
• Medication side effects (antihypertensives, diuretics, etc.) 1, 2
• Dehydration or volume depletion 1
• Anxiety or panic disorders 1

Vertigo

• Benign Paroxysmal Positional Vertigo (BPPV) - most common cause 1, 2
• Vestibular neuritis or labyrinthitis 1
• Ménière's disease 1
• Vestibular migraine 1
• Central causes (stroke, multiple sclerosis, tumors) 1

Diagnostic Approach

For Light-headedness/Presyncope

• Orthostatic blood pressure measurements (looking for drops of ≥20 mmHg systolic or ≥10 mmHg diastolic) 1
• Cardiac evaluation including ECG 1
• Medication review 2
• Blood glucose testing if diabetic 2

For Vertigo

• Examination for nystagmus (direction and triggers are diagnostically important) 1, 3
• Dix-Hallpike maneuver for BPPV diagnosis 1, 2
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew) for acute vertigo to differentiate peripheral from central causes 3, 4
• Hearing assessment if associated auditory symptoms 1

Management Approaches

Light-headedness/Presyncope

• Orthostatic hypotension: Alpha agonists, mineralocorticoids, increased salt and fluid intake, compression stockings 2
• Medication-induced: Medication adjustment or discontinuation 2
• Volume depletion: Hydration and electrolyte replacement 1
• Anxiety-related: Cognitive behavioral therapy, breathing exercises, anxiolytics if necessary 1

Vertigo

• BPPV: Canalith repositioning procedures (Epley maneuver) - highly effective first-line treatment 1, 2, 3
• Vestibular neuritis: Short course of corticosteroids and vestibular rehabilitation 2, 5
• Ménière's disease: Low-salt diet, diuretics, intratympanic steroid or gentamicin injections for refractory cases 1, 2
• Vestibular migraine: Migraine prophylaxis medications 1
• Vestibular rehabilitation: Beneficial for many causes of chronic vertigo 2, 5

Important Considerations and Pitfalls

• Avoid prolonged use of vestibular suppressant medications (antihistamines, benzodiazepines) as they can delay central compensation and recovery 6, 5
• Be alert for "red flags" suggesting central causes of vertigo: new headache, neurological symptoms, vertical nystagmus, inability to stand/walk 1
• Cervical vertigo from cervical spine disease presents differently than typical vertigo - triggered by head rotation relative to body while upright 1, 6
• Elderly patients are more likely to have multiple contributing factors to dizziness and higher risk of falls 1, 6
• Failure to respond to appropriate treatment should prompt reconsideration of diagnosis 1, 4