A 24 year old woman with a positive pregnancy test is seen in the EPAU with three days of lower abdominal pain. A transvaginal ultrasound shows she is 5 weeks pregnant, but ‘cannot rule out ectopic pregnancy’.
The patient is informed of the symptoms of ectopic pregnancy to look out for.
On mentioning ‘feeling faint’ as a red flag, she mentions episodes of room spinning for the past three days. She also feels light headed and ‘about to pass out’.
These episodes last less than a minute at a time and are provoked by head movements. There is no vomiting. She has no tinnitus or hearing problems. She has no double vision, speech problems, weakness or numbness.
On examination, her eye movements are conjugate and there is no nystagmus. A Dix-Hallpike manoeuvre is done to confirm the diagnosis.
This patient was treated as BPPV. However, she had also mentioned feeling light headed and feeling ‘about to pass out’. How should we sort these symptoms?
The official NICE CKS question for distinguishing vertigo from the other types of dizziness is “When you have dizzy spells, do you feel light-headed or do you see the world spin around you as if you had just got off a playground roundabout?”
For me, dizziness falls into one of four species (vertigo, disequilibrium, presyncope and lightheadedness) in about 80% of cases. Then there’s the 20% who complain of multiple types at once e.g. “It does feel like the room is spinning and I’m also about to fall over and pass out”. I decided to find out how best to distinguish these types, as well as think about the key questions that lead you to the differential for each of the subtypes.
True vertigo
False sense of movement. Like when you get off a merry go round.
Top questions: Is it central or peripheral?
The traditional table as found at Initial Evaluation of Vertigo:
| Type | Peripheral | Central |
| Nystagmus | Combined horizontal and torsional;inhibited by fixation of eyes onto object;fades after a few days; does not change direction with gaze to either side | Purely vertical, horizontal, or torsional;not inhibited by fixation of eyes onto object; may last weeks to months;may change direction with gaze towards fast phase of nystagmus |
| Imbalance | Mild to moderate; able to walk | Severe; unable to stand still or walk |
| Nausea, vomiting | May be severe | Varies |
| Hearing loss, tinnitus | Common | Rare |
| Nonauditory neurologic symptoms | Rare | Common |
| Latency following provocative diagnostic maneuver | Longer (up to 20 seconds) | Shorter (up to 5 seconds) |
GP Online’s quick answer: Do a head impulse test. If positive, this points to a peripheral cause. If normal, this points to central (or psychogenic) vertigo.
But how do I do a head impulse test?
Main differentials:
Central – stroke/TIA, MS, vestibular schwanoma. Can also be part of migraine.
Peripheral – – 93% of all primary care cases of vertigo are one of BPPV (last seconds to minutes), Meniere’s (lasts hours, with fullness in the ear, hearing loss and tinnitus) or vestibular neuronitis (starts bad then gets better over days to weeks). A perilymphatic fistula can also occur after head injury or surgery.
Disequilibrium
Off balance, wobbly. Like being on a moving ship.
Your eyes, vestibular system and peripheral nerves all provide input to the cerebellum to keep you balanced. In elderly patients these inputs gradually decline, leading to disequilibrium. Having musculoskeletal problems and being on antihypertensives doesn’t help. Disequilibrium can also happen in younger patients with significant neurological / vestibular disorders.
These patients feel much more balanced when they have something to hold on to e.g. furniture, as this provides them with another source of proprioception.
Presyncope
The prodrome to a vasovagal minus the actual loss of consciousness. This includes sweating, tunnelling of vision, palpitations, warmth, pallor and everything sounding distant. Much less likely to be caused by an arrhythmia than syncope (page 2649 of the ESC guidelines) but work up is generally the same.
Lightheadedness
Feeling generally disconnected from the environment. Everything may feel unreal. “Like I’m floating, doctor”. There may be some mild motion/balance problems on direct questioning, but these are not the main concern of the patient. This type of dizziness is associated with anxiety and hyperventilation/panic attacks.
Twelve fun facts about dizziness:
1. Dizziness is the fifth most common presenting complaint to primary care in the UK.
2. Vertigo is the commonest type of dizziness, and BPPV is the commonest cause of vertigo.
3. Vestibular sedatives (like prochlorperazine) do not have a role in BPPV. They may even delay central nervous compensation. The Epley manoeuvres are what you need (or alternative manoeuvres for patients with neck problems).
4. In contrast, vestibular neuronitis (peripheral vestibular nerve failure, usually triggered by a virus) or labyrinthitis (hearing symptoms as well) can benefit from short term use of a vestibular sedative. There is also a role for corticosteroids.
5. BPPV usually self resolves in 10 weeks.
6. New central vertigo will need MRI.
7. Headache is not a typical presenting complaint of anterior circulation ischaemic strokes. According to GP Online, about a third of patients with ischaemic posterior circulation strokes will have a headache, which is usually occipital. This means vertigo + new headache = potential stroke.
8. Vertigo brought on by loud noises is peripheral.
9. Meniere’s disease initially presents as episodes; eventually permanent damage occurs which could lead to deafness. This is why ENT input is advised in suspected cases.
10. Betahistine is only licensed for Meniere’s. It is not used for other causes of vertigo.
11. Vertigo going on for months with a normal MRI is most likely to be anxiety related.
12. All is not lost with persistent vertigo. It can respond to vestibular rehabilitation and physiotherapy.