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How to Manage Dizziness

Based on a lecture delivered at the Collegiate Members’ Symposium held in the College on 16 October 1998 Consultant Geriatrician, Liberton Hospital, Edinburgh INTRODUCTION In the words of W.B. Matthews, there are few physicians so dedicated to their art that they do not experience a slight decline in spirits on learning that their patient’s complaint is of dizziness. It seems as if there is a multitude of potential causes, many of which are difficult to diagnose and treat. The aim of this paper is to provide a simple, structured approach to the assessment of this challenging problem. Acute dizziness is relatively straightforward. Occasionally it will be due to sudden hypotension in the context of an acute MI or arrhythmia, or significant blood loss. Other common causes include an acute cerebellar or brain stem stroke in older age groups and, in younger patients, vestibular neuronitis or possibly a first episode of Ménière’s disease. The presentation with chronic episodic symptoms is a more difficult problem and it is this that will be explored in more detail. Dizziness is a symptom which covers a vast range of sensations, many of which are hard for patients to describe, making assessment very difficult (Box 1). However most of these sensations fall into one of three categories: a sensation of movement or vertigo; lightheadedness and pre-syncope, or loss of balance or unsteadiness. It may help patients to be offered these phrases as possible descriptions when they are struggling to explain what they feel. This then helps to decide what approach to take in their further investigation and management.