Questionnaire/history: Vertigo? - Abnormal sensation of movement of the surrounding or other person(s)? - Spinning? - Tilting? - Moving sideways; (Note: most cases in primary care due to peripheral vestibular disorder (like BPPV, acute vestibular neuronitis, Ménière's disease)) Presyncope? - Light-headedness/feeling faint? - Muscular weakness? Disequilibrium? - Sensation of unsteadiness? - Not localised to the head? - Occurring when walking and relieved with rest? (Note: most common cause 'multiple sensory deficits' (i.e. vestibular, visual and proprioceptive)? Nonspecific dizziness? - Without specific features of vertigo, disequilibrium or presyncope)? Time of symptoms? - Onset? - Duration? - Frequency? Constant or episodic? Spontaneous or triggered? - By movement? - Specific events? - Medication? Severity and effect on daily activities? - Walking? Acute intoxication with alcohol? Associated symptoms? - Nausea and vomiting? - Hyperventilation? - Otological? - Feeling of fullness in the ear? - Hearing loss? - Ear discharge? - Tinnitus? - Neurological? - Headache? - Diplopia? - Visual disturbance? - Dysarthria? - Dysphagia? - Paraesthesia? - Muscle weakness? - Ataxia? - Migraine aura? - Other? Past medical history? Family history (eg migraine, Ménière's disease)? Current medications? Drug allergies? Dizziness episodic and triggered? - Postural hypotension - BPPV Dizziness episodic and not triggered? - Ménière's disease - Vestibular migraine - Anxiety attacks Dizziness persistent and not triggered? - Acute vestibular syndrome (AVS): acute onset of persistent dizziness + nausea or vomiting, gait instability, nystagmus and head-motion intolerance lasting days to weeks) ------ Vestibular neuronitis ------ Labyrinthitis (dizziness plus hearing loss or tinnitus) ------- Posterior circulation ischaemic stroke (generally in the cerebellum or brainstem) Examination: BP (sitting or supine)? BP (standing)? Pulse? Heart? Carotid bruits? Ears? Eyes? - Vision? - Nystagmus? - Fundoscopy? Facial asymmetry? Cranial nerves? Signs of peripheral neuropathy? Cerebellar function (eg heel to toe walking)? - If abnormal: ----- Reflexes? ----- Tone in lower extremities? ----- Babinski reflex? Coordination (put the opposite heel on the knee and run the foot down and up the shin)? Unaided stand? Specific tests: Romberg's test (if positive problem with proprioception or vestibular functions)? Dix-Hallpike test (if positional vertigo affected by moving the head suggestive of BPPV)? Three-component bedside oculomotor examination HINTS (horizontal head impulse test, nystagmus and test of skew) to differentiate between a central and peripheral cause of AVS? ------ Head Impulse (person sits upright and is asked to keep their gaze fixed on the examiner, the head is then burned about 20-40 degree to one side) Normal (eyes remain fixed on the examiner)? - Normal peripheral vestibular system - May suggest central pathology (cerebral infarction) Abnormal (eyes are dragged off target and correcting movement (saccade)? - Suggestive of peripheral cause? ----- Nystagmus Unidirectional horizontal nystagmus which worsens when gazing in the direction of the nystagmus? - Suggestive of peripheral cause Vertical or torsional nystagmus or nystagmus which changes direction with gaze? - Suggestive of a central cause (centrally caused nystagmus can usually be suppressed by fixing the gaze)) ------ Test of Skew (patient is asked to look straight ahead, then each eye in turn is covered and then uncovered) - Vertical deviation/correction after uncovering? - Suggestive of central pathology (eg brainstem stroke) Unterberger's test (if rotation to one side suggestive labyrinthine damage on that side)? Investigations (if applicable): Urine dipstick? Random blood glucose? ECG? Management: According to cause Epley manoeuvre for BPPV Reference(s): BMJ: Acute vertigo NICE CKS: Vertigo Patient UK: Dizziness, Giddiness and Feeling Faint