Feature Article

An approach to the dizzy patient

Phillip D Cremer, G. Michael Halmagyi



Dizziness is common, yet it is a complaint that causes anxiety for both the patient and doctor. A diagnosis can usually be made clinically on the basis of the history and examination and, contrary to popular belief, almost all patients can be cured or helped substantially.

Key Points

  • With a careful history and examination, a diagnosis can be made for most patients with vertigo. Key points of the examination include the head impulse test and the Dix-Hallpike test.
  • Benign paroxysmal positional vertigo (BPPV) is a common cause of dizziness. Most cases eventually remit spontaneously, but treatment with particle repositioning manoeuvres is very effective.
  • Migraine-related vertigo is an underdiagnosed cause of recurrent vertigo without auditory symptoms, especially in young patients who are otherwise healthy.
  • Remember that although panic attacks can certainly cause dizziness, all patients with organic vertigo experience some degree of anxiety. Reassurance and a clear explanation go a long way in treating the anxiety component.
  • The patient with a single severe attack of vertigo should not be diagnosed with ‘a middle ear infection’. Middle ear pathology without a lesion of the inner ear never causes dizziness; the patient might have had a cerebellar infarct or haemorrhage.