The history · 1
Describing the dizziness
Patients rarely volunteer the word “vertigo”. The first task is semantic: an open, unhurried question that turns a vague complaint into a clinical category.
“Dizzy” (unqualified)
“Can you describe exactly what you feel when an episode starts?”
Ambiguous — open-ended description is needed to separate vertigo, presyncope, and disequilibrium before going further.
Why the word matters
“Dizzy” means different things to different people. For one patient it is the room spinning; for another, nearly fainting; for a third, just feeling unsteady on their feet. Each points to a different part of the body, so the first job is to find out exactly what the patient means.
The trick is to ask open questions — “describe what you feel” — rather than putting words in the patient's mouth. Let them tell the story before you start narrowing it down.
The majority of patients present with the nonspecific symptom of feeling “dizzy”, which may refer to vertigo, presyncope, disequilibrium, or light-headedness.1 Open-ended, qualitative questioning is superior to yes/no inquiry: “Can you describe exactly what you feel when an episode starts?” lets the patient narrate without being confined to medical jargon.
A note of caution: do not impose your interpretation prematurely. Patients with anxiety or PPPD often describe sensations that do not fit a classic vestibular pattern but are nonetheless real and distressing.
From the physiological standpoint, vertigo proper results from asymmetric input between or central disruption of the vestibular systems, and is an illusion of movement.2 Presyncope reflects global cerebral hypoperfusion; disequilibrium reflects failure of postural control from cerebellar, sensory, or multisensory disease, characteristically without the vertiginous illusion.
Certain patient words — “boat-like walking”, “the room spins”, “off-balance” — carry probabilistic weight, but each should be checked against an external criterion rather than trusted at face value. The aim of this first step is not the diagnosis but the category, which then determines every subsequent question.
Questions to ask
- “Dizzy” (unqualified)
Ask“Can you describe exactly what you feel when an episode starts?”
Ambiguous — open-ended description is needed to separate vertigo, presyncope, and disequilibrium before going further.
VertigoPresyncopeDisequilibrium - “Spinning” / “room moving”
Ask“Do you feel the surroundings spinning, or yourself turning?”
Suggests true rotational vertigo — typically vestibular in origin.
Vertigo - “Floating” / “detached”
Ask“Do you feel like you're floating or disconnected from your body?”
May reflect functional or anxiety-related dizziness rather than a vestibular lesion.
PPPDAnxiety - “Light-headed” / “faint”
Ask“Do you feel as though you're about to faint or black out?”
Indicates presyncope — look for orthostatic or cardiac causes, not the labyrinth.
Presyncope - “Unsteady” / “off-balance”
Ask“Is it more a sense of imbalance, as though you might fall when walking?”
Suggests disequilibrium — evaluate proprioceptive, cerebellar, and multisensory inputs.
DisequilibriumBilateral vestibulopathy - “Vertigo” (volunteered)
Ask“Is the sensation like spinning, or like being on a merry-go-round?”
Confirms rotational vertigo — most often a peripheral vestibular problem.
Vertigo