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Correspondence to Dr G Michael Halmagyi, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Camperdown, New South Wales, Australia; [email protected]
Introduction
‘There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits when they learn that their patient’s complaint is giddiness. This frequently means that after exhaustive enquiry it will still not be entirely clear what it is that the patient feels wrong and even less so why he feels it.’
From WB Matthews. Practical Neurology. Oxford, Blackwell, 1963.
While one might still share Dr Matthews’ sentiments, things are clearer now than they were then. The jobbing neurologist can now make a pretty good fist of sorting out balance problems, treating the many easy cases, and sending on the few difficult ones. Here we deal with the common causes, sorted into four categories:
First-ever attack of acute isolated spontaneous vertigo: acute vestibular neuritis/labyrinthitis versus cerebellar infarction.
Recurrent positional vertigo: easy peripheral versus difficult peripheral versus central.
Recurrent spontaneous vertigo: Ménière's disease versus vestibular migraine.
Imbalance: vestibular insufficiency versus cerebellar or other causes of ataxia.
With balance disorders, as with most of neurology, a reliable history is the cornerstone of a correct diagnosis. There are four key questions to answer:
What is the principal presenting symptom? Is it recurrent attacks of an illusion of movement, of rotation (vertigo), of falling (drop attack), or is it a constant feeling of being off-balance? If it is vertigo, then is it present mostly when rolling over in bed or when looking up? True spinning vertigo is due to unequal vestibular sensory input from the two labyrinths and is always temporary; it will abate either because the labyrinth recovers or because brainstem vestibular nuclei compensate. Therefore, a patient who reports chronic, constant spinning vertigo is describing a physiological impossibility.
How long has it been present and how long does it last? If days, does this mean it recurred several times a day and if so, what is the real duration of each attack? If the patient is assessed in the calm of the consulting room, most likely there will have been several attacks and an ongoing problem. If the patient is being seen in...