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Some Causes and Features of Dizziness

Cause

Common Features*

Diagnostic Approach

Common causes

Benign paroxysmal positional vertigo (BPPV)

Severe, brief (lasting less than 1 minute) spinning episodes triggered by moving the head in a specific direction, especially while lying down

Sometimes nausea and vomiting

Normal hearing and neurologic function

Doctor’s examination alone, typically including the Dix-Hallpike maneuver†

Meniere disease

Multiple separate episodes of vertigo, each lasting 20 minutes to 2 hours, accompanied by ringing, hearing loss, and ear fullness/pressure usually in 1 ear only

Audiogram

Gadolinium-enhanced MRI to exclude other causes

Vestibular neuronitis (probably caused by a virus)

Sudden, severe vertigo with no hearing loss or other findings

Severe vertigo may last several days, with gradual lessening of symptoms and possible development of positional vertigo

Sometimes doctor’s examination alone†

Sometimes gadolinium-enhanced MRI

Labyrinthitis (viral or bacterial cause)

Sudden hearing loss with severe dizziness or vertigo, often with tinnitus

Audiogram

Temporal bone CT scan if doctors suspect a bacterial infection

Gadolinium-enhanced MRI for people with hearing loss and ringing in ear to exclude a tumor

Medications that affect the inner ear (particularly aminoglycoside antibiotics, chloroquine, furosemide, and quinine)(particularly aminoglycoside antibiotics, chloroquine, furosemide, and quinine)

Usually hearing loss in both ears

Possible causative medication recently started

Audiogram

Sometimes electronystagmography and rotary chair tests to look for abnormal eye movements suggesting inner ear injury

Medications that affect the brain overall (particularly drugs for anxiety, depression, and seizures, as well as sedative drugs in general)

Symptoms unrelated to movement or position

No hearing loss or other symptoms

Possible causative medication recently started

Sometimes a doctor's examination alone†

Sometimes measuring blood levels of certain causative medications

Sometimes stopping the medication to see whether symptoms stop

Chronic motion sickness (common)

Persistent symptoms after acute motion sickness

Doctor's examination alone

Migraine

Multiple, separate episodes of vertigo, or chronic dizziness, sometimes accompanied by nausea

Headache or other migraine symptoms such as visual or other aura (altered sensations that come before the headache such as flashing lights) and sensitivity to light and/or noise that occur with dizziness episodes

Personal or family history of migraine

Sometimes doctor’s examination alone†

Sometimes MRI to exclude other causes

Sometimes a trial of medications to treat and prevent migraine

Less common causes, typically with ear symptoms (hearing loss and/or ringing in the ear)

Herpes zoster oticus

Facial weakness and taste loss often present along with hearing loss on the same side

Vertigo possible

Fluid-filled blisters (vesicles) on the outside of the ear (pinna) and in the ear canal

Doctor’s examination alone

Middle ear infection (acute or chronic)

Ear pain, sometimes discharge from the ear

Abnormal appearance of the eardrum during examination

Audiogram

Sometimes CT scan (for people with chronic infection)

Trauma (such as ruptured eardrum, skull fracture, or concussion)

Obvious recent trauma

Other findings depending on location and extent of damage

Sometimes audiogram

Sometimes CT scan

Vestibular schwannoma

Slowly progressive hearing loss and ringing in one ear

Rarely, numbness and/or weakness of the face

Audiogram

Gadolinium-enhanced MRI

Defect of the bone around a semicircular canal (superior semicircular canal dehiscence)

Dizziness triggered by sound or high pressure (such as when sneezing), low tone hearing loss

Audiogram with tympanometry

CT scan

Vestibular testing

Less common causes, typically without ear symptoms

Anemia

Paleness or weakness or fatigue

Blood tests

Brain stem stroke

Sudden onset, continuous symptoms

Immediate gadolinium-enhanced MRI

Bleeding in the cerebellum

Sudden onset, with continuous symptoms

Difficulty walking and with tests of coordination

Often headache

Symptoms worsen rapidly

Immediate gadolinium-enhanced MRI (or CT scan)

Multiple sclerosis

Multiple, separate episodes of neurologic symptoms such as weakness or numbness with different episodes affecting different parts of the body

Gadolinium-enhanced MRI of brain and spine

Low blood sugar (usually caused by medications for diabetes)

Recent dose increase

Sometimes sweating

Finger-stick glucose test (during symptoms if possible)

Low blood pressure (such as caused by heart disorders, blood pressure medications, blood loss, or dehydration)

Symptoms when rising, but not with head motion or while lying flat

Symptoms of the cause often obvious (such as severe blood loss or diarrhea)

Testing directed at suspected cause

Persistent perceptual postural dizziness (PPPD)

Chronic non-spinning dizziness (an internal sensation of swaying) persisting for longer than 3 months, on most days

Doctor's examination alone

Pregnancy (often not known by the person)

Sometimes late menstrual period and/or morning sickness

No ear symptoms

Pregnancy test

Psychiatric (eg, panic attack, hyperventilation syndrome, anxiety, depression)

Symptoms chronic, brief, recurrent

Unrelated to movement or position but may occur with stress or upset

Examinations of the ears and nervous system are normal

Doctor's examination alone

Syphilis

Chronic symptoms with on and off hearing loss in both ears and episodes of vertigo

Audiogram

Syphilis blood test

Thyroid disorders

Weight change

Heat or cold intolerance

Thyroid function blood tests

* Features include symptoms and results of the doctor's examination. Features mentioned are typical but not always present.

† Most people should have a full hearing test (audiogram).

CT = computed tomography; MRI = magnetic resonance imaging.