Distinguishing Vertigo from Non‑Vertiginous Dizziness

Definitions

Vertigo is a false sensation of self‑motion or spinning of the visual surroundings, whereas non‑vertiginous dizziness denotes disturbed spatial orientation without a false sense of motion. American Academy of Otolaryngology—Head and Neck Surgery defines these terms. 1

Patients describe a rotational or spinning sensation—either they feel themselves moving or the room appears to spin. This quality is characteristic of inner‑ear dysfunction. 1, 2
A confident report of “spinning” is highly specific for vestibular pathology and indicates true vertigo. 1
Vertigo commonly co‑occurs with nausea, vomiting, head‑motion intolerance, and observable nystagmus. 3
Triggers include spontaneous episodes (e.g., vestibular neuritis, Ménière disease) or positional changes relative to gravity (e.g., benign paroxysmal positional vertigo, BPPV). 1, 2

Patients use vague descriptors such as “light‑headedness,” “floating,” “foggy,” or feeling “off‑balance” without a clear spinning sensation. 1, 2

Asking “Do you feel like you or the room is spinning?” and receiving a “yes” strongly suggests vertigo. 1, 2
Asking “Does it feel like you might faint or pass out?” points toward presyncope rather than vertigo. 1
Timing helps differentiate causes: seconds to <1 min for BPPV; minutes to hours for vestibular migraine or Ménière disease; continuous days for vestibular neuritis or stroke. 1, 2, 3
Positional triggers (rolling over in bed, looking up, bending forward) are typical of BPPV and not of presyncope or psychogenic dizziness. 2

Presence of nystagmus strongly indicates a vestibular (vertigo) cause; its absence suggests a non‑vestibular dizziness. 3
The Dix‑Hallpike maneuver reproduces vertigo and a characteristic torsional nystagmus in BPPV; a negative test argues against vestibular origin. 4, 2
Severe ataxia accompanying vertigo raises concern for central (stroke) or peripheral vestibular pathology, whereas isolated gait instability without spinning suggests disequilibrium. 3

Do not rely solely on the patient’s use of the word “dizzy”; probe specifically for a spinning sensation to differentiate vertigo from light‑headedness. 1, 2
Elderly patients may present with vague dizziness rather than classic spinning, requiring careful questioning. 1
Loss of consciousness never occurs in isolated vertigo; fainting without recollection indicates presyncope or syncope. 1
Accompanying otologic symptoms (hearing loss, tinnitus, aural fullness) point toward Ménière disease or labyrinthitis, not BPPV or non‑vestibular dizziness. 1, 2

Focal neurologic deficits (dysarthria, dysmetria, dysphagia, focal motor or sensory loss, Horner’s syndrome) suggest posterior‑circulation stroke. 3
Atypical nystagmus patterns—down‑beating without torsion, direction‑changing without head movement, or gaze‑evoked nystagmus—indicate central pathology. 3
Sudden severe headache or neck pain raises suspicion for vertebrobasilar dissection or cerebellar hemorrhage. 3
Persistence of symptoms after appropriate BPPV repositioning maneuvers warrants neuro‑imaging to exclude central lesions. 3