Aetiology
Dizziness has many possible aetiologies. The most common are vestibular, cardiovascular, neurological, and psychogenic.[6]
Patients may use the term dizziness to describe vertigo, pre-syncope, lightheadedness, and imbalance (disequilibrium). Vertigo is a sensation of distorted self-motion, occurring at rest or during an otherwise normal head movement.[1] Vertigo usually indicates a problem with the peripheral (inner ear, vestibular nerve) or central (brainstem, brain) vestibular system.[7] Imbalance may be neurological in origin and lightheadedness and pre-syncope may be cardiovascular in origin. Patients with psychogenic dizziness report a variety of symptoms, such as rocking, floating, or swimming sensations.[3]
Symptoms may overlap substantially and patients most often report feeling off-balance or unsteady. Over 60% of patients experience more than one type of dizziness.[2] Evaluating the timing and triggers of dizzy episodes can help the clinician make a correct diagnosis.[8]
Vestibular
Benign positional paroxysmal vertigo (BPPV): the most common cause of vertigo, affecting 107 people in 100,000 per year.[9] In the US, BPPV is diagnosed in 17% to 42% of patients presenting with vertigo.[10] Prevalence increases with age and women are affected more frequently than men.[4][11]
BPPV is caused by loose otoconia particles (calcium carbonate crystals) in the semi-circular canals, usually the posterior canal.[10]
Patients experience vertigo with changes in head position relative to gravity (e.g., rolling over in bed or looking up).
Torsional, upbeating nystagmus provoked by the Dix-Hallpike manoeuvre is diagnostic of posterior semi-circular canal BPPV.[10]
Labyrinthitis: an acute bacterial or viral infection of the labyrinth of the inner ear. The patient often presents after an upper respiratory infection or acute otitis media. Patients may have associated symptoms of tinnitus and hearing loss, because the cochlea is located within the bony labyrinth.[12][13] Patients with acute otitis media may also report otalgia, otorrhoea, and fever.[14]
Vestibular neuritis (neuronitis): an acute peripheral neuropathy probably due to reactivation of a viral infection (e.g., herpes simplex virus), which affects the vestibular nerve. Patients present with acute onset vertigo but do not have hearing loss or tinnitus. Changes in head position exacerbate symptoms and loss of balance is a prominent feature.[12]
Meniere's disease: usually presents in middle-aged people, with fluctuating auditory and vestibular symptoms. Prevalence estimates vary from around 3.5 per 100,000 to 200 per 100,000 adults.[15][16][17][18] The underlying cause remains unknown; hereditary factors are thought to play a role.[19]
Classic Meniere's disease has the triad of vertigo, hearing loss, and tinnitus. Spontaneous vertigo attacks last 20 minutes to 12 hours with documented low- to mid-frequency sensorineural hearing loss in the affected ear before, during, or after one of the episodes of vertigo. The tinnitus is usually described as roaring in nature and may be severe. Aural fullness, a sensation of pressure and fullness in the ear, may also be present during an episode.
An atypical presentation of Meniere's disease is fluctuating hearing loss and tinnitus without vertigo. This is usually referred to as cochlear hydrops, and up to 40% of patients will eventually develop vertigo.[20]
Superior canal dehiscence syndrome (SCDS): a vestibular disorder caused by a pathological third window into the labyrinth that can present with autophony, sound- or pressure-induced vertigo, and/or altered middle-ear pressure, and chronic disequilibrium, among other vestibulocochlear symptoms.[23]
Many patients with SCDS present after head trauma and are initially diagnosed with post-traumatic vertigo, labyrinthine concussion, or perilymphatic fistula.
Perilymphatic fistula: an abnormal communication between the perilymph-filled space of the inner ear and an air-filled space in the middle ear, mastoid or cranium.[24] The fistula develops in the round or oval window. It may occur after stapes surgery, head trauma or barotrauma. It is characterised by episodic vertigo and fluctuating sensorineural hearing loss.[24]
Cholesteatoma: a mass of keratinising squamous epithelium within the middle ear or temporal bone. Patients may present with vertigo.[25] Associated symptoms include otorrhoea and hearing loss.[26]
Previous mastoid surgery with a mastoid cavity: these patients are prone to dizziness with an ear infection.
Persistent postural-perceptual dizziness (PPPD): a chronic vestibular disorder. It is one of the most common types of chronic dizziness in people aged 30 to 50 years.[27][28][29] Five diagnostic criteria must be satisfied to make the diagnosis:[30]
one or more symptoms of dizziness, unsteadiness, or non-spinning vertigo present on most days for 3 months or more
persistent symptoms occurring without provocation but exacerbated by upright posture, active or passive motion, or exposure to moving stimuli
disorder precipitated by conditions that cause vertigo including acute, episodic, or chronic vertigo or neurological or medical illness, or psychological distress
symptoms cause significant distress or functional impairment
symptoms are not better accounted for by another disease or disorder.
Neurological
Vestibular migraine: one of the most common causes of vertigo and dizziness.[31] It often occurs in patients in their 40s with a personal or family history of migraine.[32][33]
Posterior fossa tumours: include vestibular schwannomas (acoustic neuroma), meningiomas, cerebellar or brainstem tumours, and epidermoid cysts. May cause hearing loss and/or cranial nerve palsies.
Cerebellar disorders: the most common diagnoses are sporadic adult-onset degenerative ataxia (26%); idiopathic down beating nystagmus syndrome (20%); cerebellar ataxia, neuropathy, and vestibular areflexia syndrome (10%); episodic ataxia type 2 (7%); and multiple system atrophy cerebellar type (6%).[35]
Multiple sclerosis: vertigo is a common symptom. It may be peripheral (i.e., caused by involvement of the vestibular apparatus of the ear), central (i.e., caused by lesions affecting the vestibular pathways), or of combined aetiology.[36] Prolonged spontaneous attacks of vertigo occur if a demyelinating plaque occurs at the root entry zone of the vestibular nerve or nucleus, and this presents as an acute peripheral vestibular disorder, such as vestibular neuritis.[3]
Posterior circulation stroke: may be due to infarction or haemorrhage. One in five strokes affects the posterior cerebral circulation: the vertebral, basilar and posterior cerebral arteries and their branches.[37]
Symptoms are variable and often non-specific, however dizziness is one of the most common presenting symptoms. Vertigo is continuous and prolonged. Other common presenting symptoms include unilateral limb weakness, dysarthria, headache, diplopia, nausea, and vomiting.[7][37] The presentation may be very similar to vestibular neuritis.
Patients may have at least one vascular risk factor (age >60 years, hypertension, diabetes, smoking, obesity).[7]
Signs include nystagmus, unilateral limb weakness, gait ataxia, unilateral limb ataxia, dysarthria, facial numbness, Horner’s syndrome, and diplopia.[7][37] Patients usually cannot stand without support, even with the eyes open, whereas patients with acute vestibular neuritis or labyrinthitis are usually able to do so.
Lateral medullary infarction (Wallenberg’s syndrome) is caused by occlusion of the ipsilateral vertebral artery that supplies the posterior inferior cerebellar artery. Patients have prolonged vertigo lasting several days. Signs include: truncal ataxia, ipsilateral limb ataxia, diplopia, multidirectional nystagmus, ipsilateral Horner’s syndrome ipsilateral facial pain, hoarseness, dysphagia, and loss of pain and temperature sensation of the ipsilateral face and contralateral trunk and limbs.[37][38]
Vertebrobasilar insufficiency: describes transient ischaemia of the vertebrobasilar circulation. It is usually the result of atherosclerosis and affects the territory supplied by the anterior inferior cerebellar artery. Patients present with episodic vertigo, diplopia, headaches, vomiting, ataxia, blindness, imbalance, and bilateral weakness.[39] Patients may experience drop attacks, sudden falls secondary to loss of limb tone without loss of consciousness. Episodes last between 30 seconds and 15 minutes and typically start after abruptly standing or turning the head.[39]
Vertebral artery dissection: may be traumatic or spontaneous and is a cause of posterior circulation stroke in young adults. Symptoms include headache, dizziness, tinnitus, neck pain, and signs include ataxia and dysarthria.[40][41] Predisposing factors are hypertension, history of recent infection and certain connective tissue disorders (Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta, and fibromuscular dysplasia).[42][43]
Arnold-Chiari malformation type 1: an abnormality of the base of the skull, associated with brain stem and cerebellum herniation through the foramen magnum into the spinal canal. The most common symptom is occipital headache. Other symptoms may include dizziness, unsteadiness, and hearing loss.[44] Symptoms can mimic those of BPPV.[45] The condition might be asymptomatic.
Idiopathic intracranial hypertension (pseudotumor cerebri): characterised by raised intracranial pressure that is not caused by a mass lesion; associated with headache and transient poor vision. These patients are often obese and complain of clumsiness, imbalance, and dizziness rather than true vertigo. Some patients present with bilateral sixth nerve palsy or tinnitus. Incidence is increasing with the rise in obesity.[46]
Normal pressure hydrocephalus: associated with normal intracranial pressure and enlarged ventricles (hydrocephalus). Patients present with ataxia, urinary incontinence, and cognitive dysfunction.[47] The diagnosis may be difficult to establish.
Mal de debarquement syndrome: patients experience swinging, swaying, unsteadiness, and disequilibrium after exposure to motion. There may be a history of a long voyage or air travel. It is thought to be due to a conflict between the sensory inputs from the visual, vestibular, and somatosensory systems and the central vestibular nuclei, cerebellum, and parietal cortex.
Paraneoplastic cerebellar degeneration: a rare complication of cancer of the ovary, breast, or lung, or of Hodgkin's lymphoma. Auto-antibodies are thought to be directed against Purkinje cells. The anti-Yo antibody can present years before tumour detection. Anti-Tr antibody is associated with Hodgkin's lymphoma.
Secondary syphilis: may present with bilateral sensorineural hearing loss or vertigo. Late neurosyphilis may present with hearing loss, fluctuating hearing, or vestibular symptoms.[48]
Infectious
Cardiovascular
Dizziness: may be associated with palpitations or provoked by exercise if there is a cardiovascular cause.[51] Dizziness with a cardiovascular aetiology may cause pre-syncope and/or vertigo.[52] Nearly two thirds of of patients with cardiovascular causes of dizziness report vertigo, and vertigo is the only type of dizziness described in 37% of these patients.[52] Diagnosis of haemodynamic orthostatic dizziness/vertigo requires:[53]
≥5 episodes of dizziness/vertigo that occur in an upright position, and improve on sitting or lying down, AND
hypotension, tachycardia, or syncope documented on standing or tilt-table test (definite diagnosis), OR
at least one of: generalised weakness/fatigue, poor concentration, blurred vision, and/or palpitations (probable diagnosis), AND
exclusion of other possible causes.
Pre-syncope: lightheadedness without an illusion of movement. Symptoms may include generalised weakness, giddiness, headache, blurred vision, loss of vision, paraesthesia, nausea, vomiting, and diaphoresis. Symptoms last a few seconds to a few minutes. The patient senses an impending loss of consciousness but recovers before losing consciousness.[54] The mechanism is almost always a reduction in blood supply to the brain. The symptoms may be spontaneous, positional, or associated with various triggers, depending on the cause.[3] Pre-syncope is the most common subtype of dizziness in older people.[51]
Orthostatic (or postural) hypotension: one of the most common causes of pre-syncope. Patients complain of dizziness on standing.[55] The cause is impaired peripheral vasoconstriction and/or a reduction in intravascular volume. It is defined as a decrease in systolic blood pressure (BP) of ≥20 mmHg or a decrease in diastolic BP of ≥10 mmHg within 3 minutes of standing.[56] One study has suggested that BP should be tested within 1 minute of standing.[57] Orthostatic hypotension may occur in patients who take antihypertensive medication or who are volume depleted. It may be idiopathic or associated with autonomic dysfunction, such as in people with Parkinson's disease, multiple system atrophy, or diabetic autonomic neuropathy. Orthostatic hypotension is a recognised complication after bariatric surgery.[58]
Arrhythmias, ischaemia, structural heart disease, and pulmonary embolism: may cause pre-syncope.[54] One study of 881 patients who attended the emergency department complaining of pre-syncope found that 5% had serious outcomes within 30 days of the index visit. Most patients with a cardiac cause for pre-syncope were diagnosed at the initial emergency department visit. The most common cardiac causes detected in this study were atrial fibrillation and sinus node dysfunction.[54] Other cardiac causes of pre-syncope detected in the study population were: supraventricular tachycardia, complete atrioventricular block, myocardial infarction, ventricular arrhythmia, pulmonary embolism, and structural heart disease.[54] In one study of patients undergoing monitoring for recurrent unexplained syncope, an arrhythmia was present in 25% of pre-syncopal events.[59]
Postural orthostatic tachycardia syndrome: the most common autonomic disorder in young people. The patient has similar postural symptoms to people with orthostatic hypotension but with excessive postural tachycardia. Patients commonly present with complaints of postural lightheadedness, or dizziness. This is diagnosed by increased heart rate on standing, lack of orthostatic hypotension, and the absence of other conditions, such as dehydration, a primary cardiac cause, an endocrine disorder, or a nervous system disorder.[60]
Psychological
Psychophysiological dizziness (mixed physiological and psychogenic aetiology): may occur spontaneously or after a labyrinthine disorder. Patients complain of a variety of symptoms, such as rocking, floating, or swimming sensations. The symptoms may worsen with stress or fatigue.[3]
Primary hyperventilation: alveolar ventilation in excess of metabolic requirements, leading to decreased arterial partial pressure of carbon dioxide. Patients are usually young and female. Over half have a comorbid psychiatric condition. Fear, paraesthesia, and dizziness are the most common symptoms.[61]
Psychogenic dizziness: panic disorder with agoraphobia, personality disorders, or generalised anxiety are often present in patients complaining of dizziness. If the dizziness is psychogenic, patients may demonstrate inappropriate or excessive anxiety or fear. Phobic postural vertigo is characterised by dizziness in standing and walking despite normal clinical balance tests. Patients may demonstrate anxiety reactions and avoidance behaviour to specific stimuli.[62]
Phobic postural vertigo: characterised by dizziness in standing and walking despite normal clinical balance tests. Patients may demonstrate anxiety reactions and avoidance behaviour to specific stimuli.[62]
Metabolic
Diabetes mellitus: dizziness may be associated with episodes of hypoglycaemia. Other features of hypoglycaemia include shakiness, sweating, irritability, confusion, tachycardia, and hunger.[63][64] Diabetic patients with peripheral neuropathy may have more difficulty in recovering from a peripheral vestibular disorder.[65]
Autoimmune
Systemic lupus erythematosus: patients may complain of vertigo or hearing loss and may have abnormal nystagmography.[66][67]
Cogan's syndrome: an inflammatory disorder resulting in interstitial keratitis and audiovestibular dysfunction. The pathology involves plasma cell and lymphocyte infiltration of the spiral ligament, endolymphatic hydrops, and degenerative disease of the organ of Corti. There is also demyelination of the eighth cranial nerve and inner ear osteogenesis.[68]
Granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis): characterised by granulomatous lesions of the upper respiratory tract, necrotising vasculitis, and glomerulonephritis.[69]
Behcet's disease: a rare systemic autoimmune vasculitis, characterised by recurrent oral and genital ulceration, ocular inflammation and skin lesions. 15% to 47% of patients with Behcet's disease have vestibular involvement. This may cause dizziness, nystagmus and high-frequency sensorineural hearing loss.[70]
Drug-related
Ototoxic drugs: aminoglycoside antibiotics such as gentamicin and neomycin are vestibulotoxic and cochleotoxic.[71] Ototoxicity has been described for topical as well as parenteral use.[72] Aminoglycosides may cause vertigo without causing hearing loss. Toxicity with parenteral use is related to the total dose administered. Risk factors for aminoglycoside-related ototoxicity include:[73][74][75]
duration of therapy >7 days
prior exposure to aminoglycosides
high dose
age extremes (<5 years and >60 years)
presence of specific mitochondrial DNA mutations (may account for up to 60% of aminoglycoside ototoxicity)
exposure to loud sounds
renal dysfunction
other ototoxic drugs (e.g., loop diuretics).
Chemotherapeutic drugs: cisplatin, widely used in various soft-tissue neoplasms, may cause sensorineural hearing loss and tinnitus.[76] The severity of the sensorineural hearing loss is related to the cumulative dose.
Alcohol: patients report feeling 'high', dizzy, and intoxicated after ingestion.
Antihypertensives, anaesthetics, antiarrhythmics, drugs of misuse: may cause dizziness.
Certain antiepileptic drugs (oxcarbazepine, topiramate): may increase the risk of balance disorders.[77]
Toxins
Carbon monoxide poisoning: may be secondary to accidental exposure from residential boilers, central heating systems, cookers, fireplaces, and chimneys. The symptoms are often non-specific but may include vertigo, headaches, impaired concentration, pre-syncope, tachycardia, or angina.[80]
Traumatic
Post-traumatic vertigo: generally occurs as a result of blunt head trauma. Patients may present with symptoms of BPPV, a traumatic perilymphatic fistula, post-traumatic Meniere's disease, or post concussion syndrome.[81] Acute symptoms of concussion include headache, imbalance, fatigue, sleep disturbance, impaired cognition, photophobia, and phonophobia.[82]
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