History

When taking a history from a patient with vertigo, the following areas should be considered:

Current symptoms

Details of current symptoms must be identified:

• Type of vertigo (subjective or objective)
• Duration of symptoms
• Onset (sudden or insidious)
• Continuous or paroxysmal, and if paroxysmal then duration of paroxysms
• Aggravating factors, or precipitants of paroxysmal vertigo
• Any associated symptoms such as vomiting, altered hearing, cranial nerve dysfunction or limb weakness.

Risk factors

Risk factors should be identified:

• Previous episodes of vertigo
• Ear problems
• Head trauma
• Use of ototoxic drugs
• Known cardiovascular disease, or risk factors for cardiovascular disease such as increasing age, smoking, hypertension and diabetes.

Identifying potentially life-threatening central causes of vertigo is a crucial aspect of the assessment.

Central Causes

Central causes may be gradual or sudden in onset, but typically present as persistent rather than paroxysmal vertigo.

There may be significant instability, such that the patient struggles to stand and walk.

Other features such as severe head or neck pain or symptoms of brainstem dysfunction such as cranial nerve palsies or cerebellar symptoms are often present.

Central vascular causes are more common in older people and those with vascular risk factors.

Peripheral Causes

Peripheral vertigo may be associated with symptoms of cochlear dysfunction such as tinnitus or hearing loss, depending on the cause. However, the absence of hearing disturbance does not exclude a peripheral cause such as vestibular neuritis. Recurrent, very short attacks of vertigo precipitated by particular head movements, e.g. rolling in bed, are typical of BPPV, in which hearing is not usually affected.