Distinguishing True Vertigo from Lightheadedness
Ask the patient about specific triggers and duration rather than relying on their description of "spinning" versus "lightheadedness," because up to 50% of patients with confirmed vestibular disorders do not report classic room-spinning sensations. 1, 2
Why Patient Descriptions Are Unreliable
The American College of Radiology explicitly advises against relying on patient-reported terms like "dizzy" or "spinning" because these subjective descriptors have poor diagnostic accuracy. 1 Instead, focus on:
- Episode duration – Seconds suggest BPPV, minutes-to-hours suggest vestibular migraine or Ménière's disease, and days-to-weeks indicate vestibular neuritis or stroke 1
- Specific triggers – Head position changes (looking up, rolling over in bed, bending forward) point to BPPV, while standing up from lying down suggests orthostatic hypotension 1, 2
- Associated symptoms – Hearing loss, tinnitus, or aural fullness indicate Ménière's disease; headache with photophobia suggests vestibular migraine 1
Critical Questions to Ask
To Identify True Vertigo (Vestibular Pathology)
- "Do you feel like the room is moving around you, or like you are moving when you're not?" – This illusory sensation of motion defines true vertigo 3, 4
- "What makes it happen?" – Positional triggers (rolling in bed, tilting head back) strongly suggest BPPV, which accounts for 42% of all vertigo cases 1
- "How long does each episode last?" – BPPV episodes last <1 minute, while vestibular neuritis causes continuous vertigo for days 1
- "Do you have nausea, vomiting, or intolerance to head movement during episodes?" – These accompany true vestibular vertigo 1
To Identify Lightheadedness (Non-Vestibular Causes)
- "Does it happen when you stand up from lying or sitting?" – This pattern indicates orthostatic hypotension, not vestibular disease 1, 2
- "Do you feel like you might faint or pass out?" – Presyncope suggests cardiovascular causes 1
- "Are you anxious or hyperventilating when it happens?" – Panic disorder can cause lightheadedness through hyperventilation 1
- "What medications are you taking?" – Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic dizziness 1
Common Diagnostic Pitfalls
Never assume that absence of "room-spinning" excludes vestibular disease. The American Academy of Otolaryngology-Head and Neck Surgery reports that approximately 50% of BPPV patients describe their symptoms as lightheadedness, dizziness, nausea, or feeling "off balance" rather than true rotational vertigo. 3, 2 In elderly patients, BPPV may present only as isolated instability with position changes. 2
Do not overlook medication-induced dizziness. A systematic medication review is essential because drug side effects are the most common reversible cause of chronic vestibular symptoms. 1 Specifically review antihypertensives, diuretics, sedatives, anticonvulsants, and psychotropic agents. 1
Recognize that anxiety disorders can produce both lightheadedness and true vestibular dysfunction. Research demonstrates a high prevalence of genuine vestibular pathology among patients with panic disorder who report "dizziness," so psychiatric symptoms do not exclude vestibular disease. 1
Physical Examination Priorities
Once you've clarified the symptom pattern through history:
- Perform the Dix-Hallpike maneuver bilaterally for any patient with brief positional episodes, even without classic spinning 3, 2
- Check orthostatic vital signs (supine, then at 1 and 3 minutes standing) when symptoms occur with standing 2
- Conduct the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) for acute persistent vertigo lasting days, though this requires specialized training to achieve 100% sensitivity for stroke 1
When Imaging Is and Is Not Needed
No imaging is indicated for:
- Brief episodic vertigo with positive Dix-Hallpike test and no red flags 1
- Nonspecific lightheadedness without vertigo, ataxia, or neurologic deficits 1
Urgent MRI brain without contrast is mandatory for: