Diagnosing the cause of vertigo: a practical approach

Dizziness is among the commonest of chief complaints. It often presents a significant challenge to the attending physician, because the symptoms and signs are often vague and non-specific. However, a robust systematic approach can usually arrive at the diagnosis. Maintaining balance requires sensory inputs from the vestibular, visual, and somatosensory systems and the cerebellum fine-tunes inaccurate motor outputs. Causes of vertigo are most commonly otological, followed by central, somatosensory, and visual. The first question in approaching patients with dizziness is to categorise dizziness into one of the four groups: lightheadedness, pre-syncope, disequilibrium, and vertigo. Secondly, central vertigo has to be differentiated with peripheral vertigo. For peripheral vertigo, the most common cause is benign paroxysmal positional vertigo and should be specifically looked for. The tempo of the vertiginous attacks and other associated symptoms can help differentiate the other causes of peripheral vertigo, including Meniere's disease, vestibular neuronitis, labyrinthitis, and a perilymph fistula.