What are appropriate focused history questions to ask a patient presenting with vertigo?

Focused History Questions for Vertigo Evaluation

Ask about timing and triggers first—these details distinguish benign peripheral causes from dangerous central pathology far better than vague descriptions of "dizziness" or "spinning." 1

Essential Timing Questions

Duration of episodes:

• Seconds (<1 minute): Strongly suggests BPPV, the most common cause of vertigo (42% of cases) 1, 2
• Minutes to hours: Points toward vestibular migraine (14% of vertigo cases) or Ménière's disease 1, 2
• Days to weeks (constant): Indicates acute vestibular syndrome—either vestibular neuritis (41% of peripheral vertigo) or posterior circulation stroke (25% overall, up to 75% in high-risk patients) 1, 2

Onset pattern:

• Sudden versus gradual onset helps differentiate stroke from peripheral causes 1
• First episode versus recurrent attacks guides differential diagnosis 1

Critical Trigger Questions

Positional triggers:

• "Does turning over in bed, looking up, or bending down trigger your vertigo?" A "yes" strongly suggests BPPV 1, 3, 4
• "Does standing up from lying down trigger symptoms?" This points toward orthostatic hypotension (cardiovascular), not vestibular disease 1

Spontaneous versus provoked:

• Spontaneous episodes without clear triggers suggest vestibular migraine, Ménière's disease, or TIA 1, 2
• Head-motion triggered episodes indicate BPPV or bilateral vestibulopathy 1

Associated Symptom Questions

Auditory symptoms (critical for diagnosis):

• "Do you have hearing loss, ringing in the ears, or ear fullness during attacks?" These symptoms strongly suggest Ménière's disease or labyrinthitis, not BPPV or vestibular neuritis 1, 3, 5
• "Is the hearing loss fluctuating or constant?" Fluctuating hearing distinguishes Ménière's from labyrinthitis 1
• "Is it in one ear or both?" Unilateral symptoms warrant MRI to exclude vestibular schwannoma 1

Migraine features:

• "Do you have headaches with light or sound sensitivity during vertigo episodes?" Vestibular migraine is extremely common but under-recognized, especially in younger patients 1
• "Do you or your family members have a history of migraines?" Family history supports vestibular migraine diagnosis 1

Red Flag Questions (Require Urgent Imaging)

Neurological symptoms:

• "Do you have trouble speaking, swallowing, double vision, or weakness/numbness in your limbs?" Any focal neurological deficit mandates immediate MRI 1, 6
• "Can you stand or walk at all?" Severe imbalance suggests central pathology 1, 6
• "Do you have a new, severe headache with your vertigo?" This is a red flag for stroke or hemorrhage 1

Vascular risk assessment (especially if age >50):

• "Do you have high blood pressure, diabetes, atrial fibrillation, or prior stroke?" These factors increase stroke risk to 11-25% even with normal neurologic exam 1

Medication and Context Questions

Medication review:

• "What medications are you taking?" Antihypertensives, sedatives, anticonvulsants, and psychotropic drugs are leading reversible causes of chronic dizziness 1

Trauma history:

• "Have you had any recent head or neck trauma?" Post-traumatic vertigo can persist chronically 1

Psychiatric screening:

• "Do you have anxiety, panic attacks, or depression?" These are common causes of chronic dizziness and can coexist with true vestibular dysfunction 1

Common Pitfalls to Avoid

• Do not ask "Is it spinning or lightheadedness?" Patients cannot reliably distinguish these, and the distinction has limited diagnostic value 1, 2
• Do not skip timing and trigger questions even if the patient uses vague terms like "dizzy"—redirect to specific duration and circumstances 1
• Do not assume normal neurologic exam excludes stroke—75-80% of posterior circulation strokes presenting with acute vestibular syndrome have no focal deficits 1
• Do not overlook medication side effects, particularly in elderly patients with polypharmacy 1