What do you mean when you say Dizzy? – Part IV

Quality of Vestibular Symptoms

Traditional medical education stresses that most complaints of dizziness fall within one of four broad categories: Vertigo(described as a sensation or illusion of spinning or rotation which is traditionally associated with peripheral vestibular etiology, )Presyncope (technically describes a sensation of imminent loss of consciousness, but it is frequently used to categorize the sensation of lightheadedness), Dysequilibrium (traditionally associated with a neurological motor/sensory cause), and non-specific dizziness (which includes all other complaints and has traditionally been associated with psychiatric or metabolic causes {{1}}[[1]]. 1. Stanton, V., Hsieh, Y., Camargo, C., Edlow, J., Lovett, P., Goldstein, J., et al. (2007). Overreliance on symptom quality in diagnosing dizziness: Results of a multicenter survey of emergency physicians. Mayo Clin Proc, 82(11), 1319-1328[[1]].

The symptoms of vestibular disease include:

  1. Illusions of rotational motion (i.e. vertigo)
  2. Illusions of linear motion (e.g. mal de Debarquement)
  3. Illusions of spatial orientation (e.g. tilt illusion)
  4. Oscillopsia (visual blurring with head movement)
  5. Imbalance
  6. Drop Attacks (Drop attacks are sudden spontaneous falls while standing or walking, with complete recovery in seconds or minutes.)
  7. Lateropulsion (An involuntary movement of the body or turning of the gait toward one side)
  8. Autonomic accompaniments: malaise, nausea, vomiting {{2}}[[2]] 2. Halmagyi M (1996) History II. Patient with vertigo, in Disorders of the Vestibular System. Ed Baloh R, Halmagyi M. pp. 171-177. Oxford Univ Press, New York City.NY [[2]] 

Less common symptoms that may be caused by vestibular dysfunction include double vision and “visual vertigo.”  Double vision or blurred vision, most often associated with brainstem involvement, may rarely occur as a result of ocular misalignment which may be secondary to otolith or vertical (posterior and/or anterior) semi-circular canal dysfunction.

“Visual vertigo” describes a sensation of disorientation or discomfort when subjected to an environment of visual motion. Theoretically, these patients have developed an overdependence on visual information as a compensatory strategy for peripheral vestibular dysfunction {{3}}[[3]]3. Bronstein, A. (2002). Under-rated neuro-otological symptoms: Hoffman and Brookler 1978 revisted. British Medical Bulletin, 63, 213-221[[[3]].

Historically,  many physicians and vestibular specialists have relied on the patient’s report of symptom quality to categorize the “type” of dizziness. A recent survey of Emergency Department physicians shows that “symptom quality was ranked most important roughly five fold more often than the next nearest attribute” in making the diagnosis in a patient presenting with dizziness {{1}}[[1]].  Rec1. Stanton, V., Hsieh, Y., Camargo, C., Edlow, J., Lovett, P., Goldstein, J., et al. (2007). Overreliance on symptom quality in diagnosing dizziness: Results of a multicenter survey of emergency physicians. Mayo Clin Proc, 82(11), 1319-1328.[[1]].  Recent evidence suggests that patients have great difficulty in describing the quality of their symptoms reliably or consistently.  More than half of patients presenting in the Emergency Room changed the description of their dizziness only a few minutes after their initial description. To the contrary, they were able to reliably and consistently describe timing (temporal course) and triggers (precipitating factors) related to their complaints {{4}}[[4]].  4. Newman-Toker, D., Cannon, L., Stofferahn, M., Rothman, R., Hsieh, Y., & Zee, D. (2007). Imprecision in patient reports of dizziness symptom quality: a cross-sectional study conducted in an acute care setting. Presented in poster form at the American Academy of Neurology Annual Meeting on May 1 in Boston, MA.[[4]].  The authors suggest that examiners should be more focused on timing and triggers, and less dependent on the quality of symptoms when forming a diagnosis.

Next week, we continue with a discussion of temporal course, or “timing” of vestibular symptoms.

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.


  1. My primary physician told me “We don’t know what causes dizziness. Ask ten doctors and you will get ten answers.” Your blog implies that the cause can be determined. Which is most correct?

    1. Like anything else, the better tools, training and focus you have, the better chance of a correct diagnosis. A well trained and equipped vestibular specialist will find the cause of the “dizzy” complaint more often than not. There are many variables, but I would say in my clinic, we find the problem(s) about 80-85% of the time. This fits with large studies that often have an “unknown cause” in about 15% of dizzy patients. In a typical primary care office, where they don’t have specialized equipment and the doctor has to focus on many, many other complaints, the answer you got may indeed be correct.

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