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  • Updated 10.21.2020
  • Released 03.22.2000
  • Expires For CME 10.21.2023

Dizziness

Introduction

Key points

• Dizziness is a common clinical problem, affecting at least a third of the population in 1 form or another at some point.

• Dizziness is a nonspecific term that describes an unpleasant sensation of imbalance or altered orientation in space. The specific clinical manifestations of dizziness depend on which category or categories of dizziness exist: vertigo, disequilibrium, presyncope, or psychophysiological (psychogenic) dizziness.

• Vertigo is an illusion of movement that is usually rotatory, but sensations of body tilt or impulsion may also occur. Vertigo is commonly associated with nystagmus, oscillopsia, postural imbalance, and autonomic symptoms (eg, sweating, pallor, nausea, vomiting). Vertigo indicates dysfunction or imbalance within the central or peripheral vestibular pathways.

• Disequilibrium is a state of nonvertiginous altered static (eg, standing) or dynamic (eg, walking) postural balance. Patients with disequilibrium often complain of unsteadiness, imbalance, and falls. Except in cases of visual-vestibular mismatch, patients with sensory disequilibrium generally do worse in the dark and frequently have a Romberg sign on examination, whereas motor disequilibrium caused by impaired motor performance is generally not exacerbated in the dark or by closing the eyes.

• Presyncope is a syndrome characterized by a sensation of impending loss of consciousness and is commonly associated with generalized weakness, diaphoresis, nausea, and epigastric distress. Orthostatic hypotension is the most common cause, but arrhythmias, orthostatic intolerance (eg, postural orthostatic tachycardia syndrome), hyperventilation, panic attacks, and other conditions can produce presyncope. Episodes of presyncope are generally relieved with recumbency.

• Epileptic vertigo and dizziness is primarily associated with temporal lobe seizures and rarely occurs as an isolated manifestation of seizures.

• Psychophysiological (psychogenic) dizziness is a vague giddiness or dissociated sensation due to impaired central integration of sensory and motor signals in patients with acute and chronic anxiety. The dizzy sensation is typically protracted or continuous, with periodic exacerbations, often punctuated by episodes of hyperventilation-induced presyncope. Specific provocative factors may be identified, such as the presence of crowds, driving, or being in confined places (eg, elevators). Episodes are not associated with facial pallor and are not relieved with recumbency.

Historical note and terminology

In 1972, Drachman outlined a systematic approach to evaluating patients with dizziness, utilizing provocative maneuvers to help categorize patient complaints. Although the initial approach outlined by Drachman was probably overly complex, he was able to reach secure diagnoses in more than 90% of his patients. Subsequent modifications by Drachman and others have greatly helped with the clinical evaluation of dizziness.

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