The history · 3
Triggers & exacerbating factors
Most vestibular conditions have reproducible provoking factors. What sets the dizziness off — and what makes it worse — is often as diagnostic as the dizziness itself.
Ask“Is your dizziness triggered by lying down, rolling over, or sitting up?”
From trigger to mechanism
Ask what the patient was doing when the dizziness started. If it comes on when they lie down, roll over, or look up, the cause is almost always BPPV. If busy, moving visual scenes — supermarket aisles, scrolling screens — make it worse, the cause is more likely functional or migrainous. If loud sounds set it off, that is unusual and important.
Position-triggered vertigo from lying down or rolling over reflects otoconia moving within a semicircular canal — BPPV — and the Dix-Hallpike manoeuvre usually confirms it.1 Visually-induced symptoms in crowds or on screens suggest visual dependence, seen in PPPD and vestibular migraine.2
Sound- or pressure-induced vertigo — the Tullio phenomenon — points to a third-window lesion such as superior canal dehiscence. A total absence of any trigger, with abrupt continuous onset, fits vestibular neuritis — but in an older adult with vascular risk it equally demands exclusion of stroke.
Distinguish a true trigger (an event that provokes an attack from baseline) from an exacerbating factor (something that worsens ongoing symptoms). BPPV, the Tullio phenomenon, and orthostatic presyncope are genuinely triggered; the head-motion intolerance of an uncompensated peripheral lesion or of PPPD is an exacerbator, not a trigger, and misreading one for the other sends the differential astray.
The most useful negative in the whole history is the spontaneous, untriggered, continuous first-ever attack: that is the acute vestibular syndrome, where the only question that matters is peripheral versus central.
Questions to ask
- Position changes
Ask“Is your dizziness triggered by lying down, rolling over, or sitting up?”
Otoconia in a semicircular canal cause brief, position-triggered episodes — BPPV.
BPPV - Visual motion / complexity
Ask“Does it worsen in crowds, supermarkets, or while scrolling on a screen?”
Visually-induced dizziness suggests PPPD (visual dependence) or vestibular migraine.
PPPDVestibular migraine - Head movement
Ask“Does rapid head turning make you feel dizzy or unsteady?”
Movement-provoked symptoms point to vestibular hypofunction, vestibular migraine, or BPPV depending on duration.
Vestibular neuritisVestibular migraineBPPV - No trigger (spontaneous)
Ask“Did the symptoms begin suddenly, without any particular trigger?”
Spontaneous, continuous vertigo is often post-viral neuritis — but mandates exclusion of posterior-circulation stroke.
Vestibular neuritisPosterior circulation stroke - Loud sound / pressure (Tullio)
Ask“Is it brought on by loud sounds, coughing, straining, or nose-blowing?”
Sound- or pressure-evoked vertigo suggests a third-window lesion such as superior canal dehiscence or perilymph fistula.
Superior canal dehiscencePerilymph fistula - Stress / anxiety
Ask“Do you feel worse during emotional stress or panic?”
Stress-provoked dizziness suggests PPPD, psychogenic dizziness, or an anxiety-related syndrome.
PPPDAnxiety