Diagnosing dizziness: Is it vertigo?

When I’m asked to make an evaluation of a dizzy patient and all I know is that they feel dizzy, the best tool I have is their story. It is by far the most important thing, and nine times out of 10 I can make a diagnosis just from a good story.

I also do an exam, of course, to augment the story and help me narrow down exactly what we’re dealing with, but most of the time the explanation of how the symptoms came on is enough to get started in the right direction.

I want to know when it started. What does it feel like? Is there spinning or just a sense of lightheadedness? How long did it last? How severe is it? Are you just a little off or totally incapacitated by the dizziness? Does anything cause more dizziness or make it feel better? Answering these questions can give me a very good idea of what’s going on.

 

The inner ear

The role of our inner ear, or vestibular system, is basically to detect the movement of our body relative to gravity and the ground we’re walking on. It sends this information to the brain, which then generates the appropriate motor responses to keep our eyes in line with our head and keep us upright. It is a really important part of our physiology.

One way our inner ear does this is through the vestibulo-ocular reflex. It’s a reflexive eye movement that the inner ear triggers during head movement to keep an image centered on our retina. So, when we move our head, our eyes move in certain ways to keep our visual field stable. Frequently, when there is an inner ear problem, this reflex is impaired.

In addition to the inner ear, our eyes contribute important information to the brain with respect to our sense of balance. If our sight is impaired, a problem with balance may result. Finally, the sensory nerves in our legs and feet provide more information to the brain. Patients who suffer from neuropathy frequently have problems with balance.

So, when we think about our balance system, it’s really our brain getting information from these different sources. The brain gets that information, assimilates all the data and keeps us walking in a straight line. If there are any problems with any of these sources of inputs, we have problems with balance.

 

Vertigo

Although there are a number of ways to describe dizziness, vertigo is described as the room is spinning out of control. A description like this has a direct correlation to the inner ear, whereas lightheadedness, for example, can be caused by dehydration or low blood pressure. Medications may also cause vague sensations of dizziness; I recommend all patients with dizziness review their medications with their physician.

Because our inner ear is located deep within the skull, it’s impossible to look at it directly. So, we have to find other ways to infer what’s going on in the inner ear. We have tests we will do in order to try and get that information.

There are primarily three different types of vertigo I see in my practice. Each one has a unique and distinct cause. I will break down each of the three types and over the next three weeks will go over causes, tests and treatments for each.

 

Recurrent positional vertigo

This is the type of vertigo a patient experiences when they get into a certain position and it causes the room to spin. It is very predictable. Certain head movements will trigger the symptoms, but in between these episodes patients feel pretty normal.

 

Recurring vertigo attacks

Patients will come in after having a vertigo attack where there were no provoking factors. The classic story is a patient says, “I get this roaring sound in my ears and my hearing goes out. Then I get the spins. It lasts for several hours then goes away and I feel OK the next day.”

 

Sudden onset vertigo

This is the person who has never had vertigo in their life. Everything seems pretty normal, and then all of a sudden they get the worst vertigo you can imagine. They can’t make it stop. Frequently they experience severe nausea and vomiting. These are the patients that usually end up in the ER. These are the people who come see me and say, “I was on a business trip and I got the spins. I had to stay in my hotel room with the lights off just to keep myself from vomiting.” It’s very, very debilitating.

 

Talk to a doctor

It’s important to remember that not all dizziness is vertigo or related to the inner ear. But if the room is spinning and you feel your eyes jerking back and forth, it is probably one of the three types of vertigo listed here.

Dizziness is among the most common presenting symptoms that primary care providers and emergency room physicians encounter. Don’t be afraid to see your primary physician if you feel that vertigo is affecting your daily life. It doesn’t have to.

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