Dizziness or vertigo is a very frequent cause of consultation in a neurology clinic. In the mind of the general public it is not clear how to describe what there are feeling when it comes to dizziness. Many patients have already seen an ENT, an ophthalmologist, a cardiologist beside their family physician before coming to the neurologist. The patients commonly use fainting or near-fainting, light-headedness, unsteadiness, imbalance, dizziness or vertigo and not rarely the description changes within the same or in the next visit. Different patients having same disorder will describe their dizziness differently. Vertigo is a sensation of movement of the patient or his surroundings when in reality none of them is moving. The patient feels that he/she, the environment or both are spinning or moving. Vertigo is a symptom not a final diagnosis. It can be “the” major symptom or part of a multiple symptoms such as gait difficulty, nausea, vomiting, double vision, reduced hearing or a tinnitus; ringing in the ear. 

Vertigo may be transient, episodic, recurring or chronic. It can be of short duration of seconds to minutes or several days or weeks. Most frequent causes of dizziness are related to a disorder of the brainstem, cerebellum, inner or middle ear or vestibulocochlear nerve but low blood pressure, severe low blood sugar or anemia can also cause dizziness as can anxiety or depression. 

Disorders causing vertigo are called peripherals when the inner ear or the vestibulocochlear nerve are affected or central when the cause is in brainstem or the cerebellum. Most common peripheral causes are benign paroxysmal positional vertigo, vestibular neuronitis and Meniere’s disease. Stroke, multiple sclerosis and tumors are common central causes of vertigo. Dizziness can be part of a migraine attack and the there is a variation of migraine called vestibular migraine. Vertigo can also be a manifestation of a psychiatric disease such as panic attacks, anxiety or depression. In the elderly; drugs side effects or interactions as well as likely diminished visual and acoustic capabilities often play a role. A detailed history taken from the patient is a clue for an accurate diagnosis. There are important points to get from the history; was the onset severe affecting the balance and the gait? How long did it last, minutes, days, weeks? Was it a unique episode or chronic and recurring? How frequent dizziness episodes are? Any identified triggers like position changing? Any associated symptoms such as tinnitus, hearing loss, double vision, vomiting? 

Neurological examination and ears functional assessment to look for abnormalities that would orient the diagnosis to a central or peripheral cause. Orthostatic hypotension specially if the patient is taking antihypertensive or other cardiovascular drugs should also be looked for. A cardiology consultation can be useful to look for a potential cardiac cause such as arrythmia or conduction block. Clinical evaluation is completed with investigations such as brain MRI when indicated. I often refer to a ENT to look for a cause affecting the middle or the inner ear. The treatment as always depends on the accurate diagnosis and the underlying cause. Vestibulo-cochlear causes are logically treated by the ENT. Benign paroxysmal positional vertigo is corrected with Epley’s maneuver that should be done by an experienced physician. Central causes when found such as multiple sclerosis or stroke are managed by the neurologist. Acoustic neurinomas are referred to a neurosurgeon for appropriate management and to see if a surgical removal is indicated. 

Dizziness or vertigo is an unpleasant sensation often affects the quality of life of people; a visit to your neurologist can confirm a neurological cause or if a neurological cause is discarded you can be referred to another specialist to look for another cause.