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Dizziness

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Peripheral Vestibular Causes

  • Benign paroxysmal positional vertigo (BPPV): Sudden onset, triggered by head movements, lasts seconds.
  • Meniere’s disease: Recurrent episodes, associated with hearing loss, tinnitus, and aural fullness.
  • Vestibular neuritis: Acute onset, severe vertigo, no hearing loss, often follows viral infection.
  • Labyrinthitis: Similar to vestibular neuritis but with hearing loss.
  • Acoustic neuroma: Gradual onset, unilateral hearing loss, tinnitus, unsteadiness.

Central Vestibular Causes

  • Stroke/TIA: Sudden onset, risk factors present (hypertension, diabetes), may have focal neurological signs.
  • Multiple sclerosis: Recurrent episodes, may have other neurological signs (e.g., optic neuritis).
  • Migraine-associated vertigo: Recurrent, associated with headache, photophobia, aura.
  • Brain tumour: Progressive, may have focal neurological deficits, raised intracranial pressure signs.
  • Chiari malformation: Vertigo triggered by straining or coughing, associated with occipital headache.

Cardiovascular Causes

  • Orthostatic hypotension: Dizziness on standing, associated with dehydration or antihypertensive medication.
  • Arrhythmias: Sudden onset, palpitations, may cause syncope.
  • Aortic stenosis: Exertional dizziness, associated with chest pain, syncope, ejection systolic murmur.
  • Carotid artery stenosis: TIA-like symptoms, transient dizziness, risk factors for atherosclerosis.
  • Vasovagal syncope: Preceded by nausea, diaphoresis, and pallor, usually triggered by stress or standing for long periods.

Other Causes

  • Anaemia: Gradual onset, fatigue, pallor, may have associated symptoms like shortness of breath.
  • Hypoglycaemia: Sudden onset, sweating, tremors, confusion, often in diabetic patients.
  • Medications: Antihypertensives, diuretics, and antidepressants can cause dizziness as a side effect.
  • Psychogenic causes: Anxiety disorders, panic attacks, often associated with hyperventilation and palpitations.

Key Points in History 🥼

Onset and Duration

  • Acute onset: Suggests peripheral vestibular causes, stroke, or arrhythmias.
  • Chronic or recurrent: Consider central causes such as multiple sclerosis or migraine-associated vertigo.
  • Episodic with triggers: BPPV (head movement), Meniere’s disease (dietary triggers), vasovagal syncope (prolonged standing).

Character of Dizziness

  • Vertigo (spinning sensation): Suggests vestibular causes such as BPPV, vestibular neuritis, or Meniere’s disease.
  • Presyncope (feeling of faintness): Suggests cardiovascular causes such as orthostatic hypotension or arrhythmias.
  • Disequilibrium (feeling of imbalance): Consider neurological or musculoskeletal causes.
  • Non-specific dizziness: May be related to anxiety, hyperventilation, or medication side effects.

Associated Symptoms

  • Hearing loss or tinnitus: Suggests Meniere’s disease, acoustic neuroma, or labyrinthitis.
  • Headache: Consider migraine-associated vertigo, stroke, or central causes like a brain tumour.
  • Focal neurological deficits: Hemiparesis, dysarthria, or ataxia suggest a central cause such as stroke
  • Palpitations: Suggests arrhythmias or anxiety disorders.
  • Chest pain or dyspnoea: Consider cardiac causes such as aortic stenosis or myocardial infarction.
  • Visual disturbances: Diplopia or visual loss suggests central causes, particularly stroke or multiple sclerosis.

Background

  • Past medical history: Key conditions include cardiovascular disease, diabetes, neurological disorders, and previous episodes of vertigo.
  • Medication history: Review for drugs that may cause dizziness (e.g., antihypertensives, diuretics, antidepressants).
  • Family history: Important for hereditary conditions such as Meniere’s disease or cardiovascular conditions.
  • Social history: Alcohol intake, occupational hazards, and impact on daily activities.

Possible Investigations 🌡️

Blood Tests

  • Full blood count: To check for anaemia or infection.
  • Electrolytes and glucose: To identify metabolic causes such as hypoglycaemia or hyponatraemia.
  • Thyroid function tests: To assess for thyroid disorders.
  • BNP or troponins: If heart failure or myocardial infarction is suspected.

Imaging and Specialist Tests

  • MRI brain: To assess for central causes such as stroke, multiple sclerosis, or brain tumours.
  • CT head: Useful in acute settings, particularly in trauma or to exclude haemorrhage.
  • Echocardiogram: To assess for structural heart disease such as aortic stenosis.
  • Electrocardiogram (ECG): To check for arrhythmias or signs of myocardial ischaemia.
  • Audiometry: If hearing loss or tinnitus is present, to assess for Meniere’s disease or acoustic neuroma.
  • Dix-Hallpike maneuver: Diagnostic for BPPV.

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Cardiovascular