How do you differentiate vertigo from lightheadedness in a patient?

Differentiating Vertigo from Lightheadedness

The key distinction is that vertigo is a false sensation of rotational movement or spinning (either self or environment), while lightheadedness is a non-specific sensation of feeling faint, "off balance," or unsteady without any rotational component. 1, 2

Primary Distinguishing Features

Vertigo Characteristics

• Patients describe a confident sensation of spinning or rotation – either they are spinning or the room is spinning around them 3, 2
• This rotational quality is specific for inner ear (vestibular) dysfunction and indicates asymmetrical vestibular input to the brainstem 3, 4
• May be accompanied by nausea, vomiting, and intolerance to head motion 5
• Often triggered by specific head positions or movements 5, 2

Lightheadedness Characteristics

• Patients describe vague, non-specific sensations such as feeling "off balance," unsteady, or "in a fog" 1, 2
• Common descriptors include feeling faint, weak, or about to pass out (presyncope) 6, 7
• The absence of a confident description of spinning argues against inner ear dysfunction and suggests either central (neurologic) or non-vestibular causes 1, 3
• May indicate cardiovascular causes like orthostatic hypotension or medication side effects 5, 2

Clinical Approach to Differentiation

Focus on Timing and Triggers Rather Than Patient's Subjective Description

The most diagnostically valuable information comes from timing and triggers, not the patient's vague description of "dizziness" 2, 7

Key questions to ask:

• Duration: Seconds (suggests BPPV), minutes to hours (suggests vestibular migraine or Ménière's), or days to weeks (suggests vestibular neuritis or stroke) 5, 2
• Triggers: Positional changes (BPPV), standing up (orthostatic hypotension), or spontaneous (vestibular migraine, Ménière's) 5, 3, 2
• Associated symptoms: Hearing loss, tinnitus, aural fullness (Ménière's disease), headache with photophobia (vestibular migraine) 5, 2

Physical Examination Maneuvers

Perform the Dix-Hallpike maneuver bilaterally to identify BPPV, looking for:

• Latency period of 5-20 seconds before symptoms begin
• Torsional, upbeating nystagmus toward the affected ear
• Vertigo and nystagmus that increase then resolve within 60 seconds 5, 2

Obtain orthostatic vital signs (blood pressure and heart rate supine, then at 1 and 3 minutes standing) to evaluate for orthostatic hypotension causing presyncope 3, 2

Assess for nystagmus, which is the only objective sign in vertigo:

• Peripheral vertigo: unidirectional, horizontal-rotatory nystagmus
• Central vertigo: direction-changing, vertical, or downbeating nystagmus 2, 8

Common Clinical Pitfalls to Avoid

Never assume the absence of room-spinning excludes BPPV – up to 50% of BPPV patients report lightheadedness or feeling "off balance" rather than true rotational vertigo 3

Do not rely solely on the patient's description of "dizziness" – patients have difficulty describing the quality of their symptoms but can more consistently identify timing and triggers 2, 7

Recognize that concussion-related dizziness typically presents as lightheadedness rather than true vertigo, with patients describing vague sensations of being "off balance" or "in a fog" 1

Consider medication side effects as a leading reversible cause of lightheadedness, particularly antihypertensives, diuretics, sedatives, and vestibular suppressants 5, 2

When to Suspect Central (Dangerous) Causes

Red flags requiring urgent evaluation include:

• Focal neurological deficits on examination
• Sudden unilateral hearing loss
• Inability to stand or walk
• New severe headache accompanying dizziness
• Downbeating or other central nystagmus patterns
• Failure to respond to appropriate vestibular treatments 2

For acute persistent vertigo, perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew), which has 100% sensitivity for detecting stroke when performed by trained practitioners, compared to only 46% sensitivity for early MRI 2, 7