What history should be taken in a patient with vertigo?

History Taking in Vertigo Cases

Begin by determining whether the patient is experiencing true vertigo (a sensation of spinning or rotation) versus vague dizziness, lightheadedness, or presyncope, as this single distinction guides the entire diagnostic approach. 1, 2

Define the Type of Sensation

• Ask the patient to describe their exact sensation rather than accepting the word "dizziness," which is non-specific and often misleading 1, 3
• True vertigo is a false sensation of self-motion or that the visual surroundings are spinning or flowing 1
• Lightheadedness or feeling faint suggests presyncope, NOT vertigo, and requires cardiovascular evaluation 2
• Unsteadiness or off-balance without spinning represents non-specific dizziness rather than true vertigo 2
• Note that elderly patients may not describe frank spinning but rather "vestibular disturbance" or vague dizziness, even with true inner ear pathology 1

Timing and Duration (Most Critical Distinguishing Feature)

The duration of vertigo episodes is the single most important historical feature that distinguishes causes. 2, 3

• Seconds only: Benign paroxysmal positional vertigo (BPPV), lasting less than one minute 1, 2
• Minutes: Possible transient ischemic attack, stroke, or vestibular migraine 1, 2
• Hours: Vestibular migraine (typically) or Ménière's disease 1
• Days to weeks of constant symptoms: Vestibular neuritis (12-36 hours of severe vertigo, then days of disequilibrium) or labyrinthitis 1

Onset and Triggering Factors

• Ask if vertigo is provoked by head position changes, which strongly suggests BPPV 1, 2
• Determine if onset is spontaneous or triggered by specific movements, visual stimuli, or pressure changes 1
• Inquire about motion intolerance and light sensitivity, which suggest vestibular migraine 1
• Ask about pressure changes (coughing, sneezing, loud sounds) that might suggest superior canal dehiscence or perilymphatic fistula 3

Associated Otologic Symptoms

Ask specifically about concurrent hearing symptoms before, during, or after vertigo attacks. 1

• Fluctuating hearing loss, tinnitus, and aural fullness occurring with vertigo episodes suggest Ménière's disease 1
• Sudden profound hearing loss with prolonged vertigo suggests labyrinthitis 1
• Asymmetric or unilateral hearing loss with chronic imbalance (rather than episodic vertigo) suggests vestibular schwannoma 1
• No hearing symptoms with isolated vertigo suggests vestibular neuritis or BPPV 1

Migraine History

Thoroughly inquire about current or past migraine history, as vestibular migraine closely mimics other causes and is extremely common. 1

• Ask about headaches with pulsating quality, unilateral location, moderate-to-severe intensity, or aggravation by routine physical activity 1
• Inquire about photophobia and phonophobia during or around vertigo episodes 1, 3
• Ask about visual auras (bright scintillating lights, zigzag lines, scotomas) that develop gradually over 5-20 minutes 1
• Note that vestibular migraine can present with episodes lasting minutes to over 24 hours, making duration alone insufficient for diagnosis 1

Neurologic Red Flags

Actively screen for symptoms suggesting central (stroke) causes, which require immediate intervention. 1, 4

• Ask about dysphagia, dysphonia, or difficulty swallowing, which suggest brainstem involvement 1
• Inquire about visual blurring, diplopia, or drop attacks without loss of consciousness 1
• Ask about facial numbness, weakness, or other focal neurologic symptoms 1
• Determine if there are falls or "drop attacks" during episodes 1
• Confirm that loss of consciousness NEVER occurs with peripheral vertigo; fainting suggests a different diagnosis 1
• New severe headache accompanying vertigo mandates immediate stroke evaluation 3

Past Medical and Otologic History

• Obtain thorough otologic history: prior ear surgery, chronic ear infections, otorrhea, otalgia, or previous hearing loss 1
• Review vascular risk factors: hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation (stroke risk) 1, 4
• Ask about autoimmune conditions that may present with bilateral fluctuating hearing loss and vertigo 1
• Inquire about infectious exposures: recent viral illness (vestibular neuritis), Lyme disease, syphilis 1
• Review neurologic history: multiple sclerosis, prior strokes, cerebellopontine angle tumors 1

Medication and Substance History

• Document all medications, particularly blood pressure medications, diuretics, and chronic vestibular suppressants 1
• Ask about tobacco, caffeine, alcohol, and recreational drug use 1
• Inquire about herbal or alternative medications 1

Functional Impact and Fall Risk

• Assess mobility, balance, and home support, particularly in elderly patients who have a 12-fold increased fall risk 4
• Evaluate the emotional impact of recurrent vertigo, hearing loss, and tinnitus on quality of life 1

Common Pitfalls to Avoid

• Never rely solely on the patient's use of "spinning" versus "lightheadedness"; instead focus on timing, triggers, and associated symptoms 3
• Do not assume normal neurologic symptoms rule out stroke, as 75-80% of patients with posterior circulation stroke causing acute vestibular syndrome have no focal neurologic deficits 2, 4, 3
• Recognize that absence of hearing loss does NOT exclude serious pathology like stroke or vestibular neuritis 1