The history · 5
The wider history
The background fills in what the presenting complaint cannot: the drugs and comorbidities that cause vertigo, the psychological loop that sustains it, and the contexts — childhood, old age, work — that change its meaning.
Medications & past medical history
A patient's other conditions and medicines often explain the dizziness. A history of migraine, of high blood pressure or stroke, of ear surgery, or of certain antibiotics can all be the missing piece.
A migraine history supports vestibular migraine; vascular risk factors raise concern for ischaemic vertigo. Ototoxic drugs — aminoglycosides, loop diuretics, some chemotherapeutics — cause bilateral vestibular loss, presenting as imbalance and oscillopsia rather than spinning vertigo.1 Sedatives and anticonvulsants can suppress central compensation and cause drug-induced dizziness in their own right.
Medication reconciliation is part of the vestibular history, not an afterthought — especially in the polypharmacy of older adults, where the cumulative effect of several agents can tip a compensated patient into chronic disequilibrium. Ask specifically about recent hospitalisation, antibiotic courses, and chemotherapy in any patient with bilateral signs or worsening unsteadiness.
- Migraine history
Ask“Have you ever had migraine, or headaches with visual or sensory aura?”
Supports vestibular migraine — a common cause of episodic vertigo with or without headache.
Vestibular migraine - Vascular risk factors
Ask“Do you have high blood pressure, diabetes, or a previous stroke or TIA?”
Raises concern for vertebrobasilar insufficiency or ischaemic vertigo, especially in older adults.
Posterior circulation stroke - Ear disease / surgery
Ask“Have you had chronic ear problems or ear surgery (mastoidectomy, tympanoplasty)?”
May indicate labyrinthine injury, labyrinthitis, or post-surgical vestibular dysfunction.
LabyrinthitisPerilymph fistula - Ototoxic drugs
Ask“Have you recently had strong antibiotics (e.g., gentamicin) or loop diuretics?”
Risk of bilateral vestibular loss — imbalance and oscillopsia without true spinning vertigo.
Bilateral vestibulopathy - Sedatives / antidepressants
Ask“Are you taking medication for anxiety, depression, or seizures?”
Can suppress central vestibular compensation or cause drug-induced dizziness.
Disequilibrium - Polypharmacy
Ask“Have there been recent changes to your medications, or are you on many at once?”
Increases the risk of multifactorial dizziness, especially in the elderly.
DisequilibriumPresbyvestibulopathy
Psychological & functional contributors
Anxiety and dizziness feed each other. Worry about the next attack can keep symptoms going long after the original problem has settled — and this is common, real, and treatable.
The relationship is bidirectional: vestibular disease can trigger anxiety, and anxiety amplifies and perpetuates dizziness. PPPD is the archetype — chronic non-spinning dizziness persisting after a benign vestibular insult, sustained by maladaptive sensory reweighting.2,3 Screen with questions such as “Do you feel anxious when you are dizzy?” and “Have symptoms persisted despite normal tests?”
Recognising the functional overlay early opens the door to vestibular rehabilitation, CBT, and SSRIs — and avoids the iatrogenic spiral of repeated negative testing. The psychological history does not negate the patient's experience; it reframes the management toward a biopsychosocial plan.
- Anxiety with dizziness
Ask“Do you feel anxious or fearful when you are dizzy?”
A psychogenic overlay — anxiety amplifies the perception of dizziness.
AnxietyPPPD - Fear of falling
Ask“Are you afraid of falling even when you feel physically stable?”
Indicates functional dizziness or heightened fall anxiety, common in the elderly.
PPPDAnxiety - Panic symptoms
Ask“Do you get sudden palpitations, breathlessness, or a feeling of dread?”
May reflect panic attacks, often comorbid with chronic dizziness or PPPD.
AnxietyPPPD - Persistent despite normal tests
Ask“Have your symptoms continued despite normal tests and treatment?”
Strongly points to PPPD.
PPPD - Hypervigilance
Ask“Do you frequently monitor your body for signs of imbalance?”
Suggests somatosensory amplification, characteristic of functional dizziness.
PPPD
Children
Children rarely say “vertigo”. They may say they feel funny, that the room is turning, or simply become pale, frightened, and clingy during an attack. Surrogate clues — motion sickness, a family history of migraine — matter.
Vestibular migraine and benign paroxysmal vertigo of childhood are among the commonest causes in children, the latter a recognised migraine precursor.4 Ask about motion sickness, episodic unsteadiness, and a family history of migraine. Persistent or unexplained vertigo, or any focal sign, still warrants imaging to exclude posterior-fossa pathology.
A detailed developmental and family history reframes the differential in children. With normal imaging and no focal deficit, functional dizziness should be entertained in adolescents, particularly with anxiety or somatisation.
- Motion sickness
Ask“Does the child get carsick or motion-sick easily?”
Commonly associated with vestibular migraine; may be an early marker of susceptibility.
Vestibular migraine - Recurrent unsteadiness
Ask“Are there recurrent brief episodes of unsteadiness or clumsiness?”
May suggest benign paroxysmal vertigo of childhood or an evolving migraine variant.
BPV of childhoodVestibular migraine - “Room spinning”
Ask“Has the child ever described the room spinning?”
Verbalisation is limited in children, but this points toward true vertigo episodes.
Vestibular migraineBPV of childhood - Family history of migraine
Ask“Is there a family history of migraine?”
Strongly supports vestibular migraine in the child.
Vestibular migraine
Older adults
In older people, dizziness is usually multifactorial — failing vision, reduced sensation in the feet, several medicines, and age-related decline of the balance organ all add up. Falls are the danger.
Age-related decline in vestibular function — presbyvestibulopathy — is bilateral, progressive, and often unrecognised.5 Combined with visual and proprioceptive decline and polypharmacy, it produces chronic imbalance and fall risk. Screen for falls, orthostatic blood-pressure change, drug effects, neuropathy, and visual deficit.
Vertigo in the elderly rarely stems from a single cause; a systems-based, multifactorial assessment and an individualised plan — medication review, gait and balance screening, vestibular rehabilitation — beats the search for one unifying lesion.
- Falls / near-falls
Ask“Have you had any falls or near-falls?”
Suggests balance impairment from multisensory decline or vestibulopathy.
PresbyvestibulopathyDisequilibrium - Antihypertensives / sedatives
Ask“Are you taking blood-pressure tablets or sedatives?”
May contribute to orthostatic hypotension, sedation, or central suppression.
PresyncopeDisequilibrium - Visual / proprioceptive deficits
Ask“Do you have problems with vision or with sensation in the feet?”
Visual and proprioceptive deficits compound vestibular loss in the elderly.
PresbyvestibulopathyDisequilibrium - Polypharmacy
Ask“How many regular medications are you taking?”
Increases the risk of drug-induced dizziness and confounds the diagnosis.
Disequilibrium
Occupational & social context
What someone does for work, and how dizziness affects their daily life, matters for safety and for support. Vertigo in a pilot, driver, or someone working at height is a serious safety issue.
Document safety-sensitive occupations, the functional impact on work, and the social consequences of chronic dizziness.6,7 Occupational noise and vibration exposure may even contribute to vestibular disease, and avoidance of public transport or crowds points to visually-induced dizziness.
The occupational and social history carries both management and medicolegal weight — return-to-work certification, fitness to drive, and disability assessment all hinge on an accurate account of functional impairment.
- Safety-sensitive work
Ask“Does your work involve heights, machinery, or driving?”
Identifies safety-critical roles (pilots, drivers, crane operators) where vertigo carries serious risk.
- Impact on work
Ask“Have your symptoms affected your ability to work?”
Assesses functional impairment and the need for workplace accommodation.
- Social impact
Ask“Have your symptoms affected your social life or relationships?”
Suggests psychosocial impact and a possible functional or anxiety-related disorder.
PPPDAnxiety - Avoidance behaviour
Ask“Do you avoid public transport, crowds, or fast-moving visual scenes?”
Indicates visually-induced dizziness — possibly PPPD or vestibular migraine.
PPPDVestibular migraine