Dizziness Type Classifier
Step 1 — Anchor to History, Not Symptom Quality
Do NOT rely on whether the patient says "spinning" vs "lightheaded." Many patients describe their dizziness inconsistently, and symptom quality alone is unreliable. Instead, focus on timing, triggers, and associated symptoms.
Ask:
- When does it happen? (standing, lying down, head movement, out of the blue)
- How long does each episode last? (seconds, minutes, hours, constant)
- What makes it worse?
- What other symptoms come with it?
Step 2 — Is This Vestibular / Vertigo?
Suspect vestibular if ALL of the following:
| Feature |
Vestibular pattern |
| Trigger |
Head movement makes it worse (patient afraid to move) |
| Duration |
Episodes last seconds to hours; NOT continuously present for months |
| Quality |
Spinning, whirling, tilting — but vague descriptions do NOT exclude it |
| Exam |
Nystagmus present (or Dix-Hallpike positive) |
| Associated |
Nausea, postural instability |
⚠️ Constant dizziness lasting months is usually NOT vestibular — central adaptation corrects vestibular lesions within weeks.
Triggers that point to vestibular:
- Rolling over in bed, bending neck back, lying down → positional vertigo (BPPV)
- Head motion in any direction → vestibular disorder (all vestibular dizziness worsens with head movement)
- Coughing, sneezing, Valsalva → superior canal dehiscence or perilymphatic fistula
→ If vestibular: proceed to Peripheral vs Central Vertigo Differentiator
Step 3 — Is This Presyncope?
Suspect presyncope if:
| Feature |
Presyncope pattern |
| Trigger |
Upright posture (standing or seated); NOT lying down |
| Quality |
"Nearly blacking out," feeling of impending faint, warmth, pallor, visual greyout |
| Duration |
Seconds to minutes |
| Associated |
Diaphoresis, nausea, palpitations, chest discomfort, dyspnoea |
| History |
Cardiac disease, dehydration, antihypertensives, antidepressants |
⚠️ If dizziness occurs while lying down, think cardiac arrhythmia — not orthostatic hypotension.
Subtypes to consider:
- Orthostatic hypotension — occurs on standing; confirm with BP/pulse lying → standing (≥20 mmHg systolic drop)
- Cardiac arrhythmia — occurs lying or sitting; palpitations may be present
- Vasovagal — triggered by pain, emotion, prolonged standing
→ If presyncope: evaluate as syncope (orthostatic vitals, ECG, cardiac history)
Step 4 — Is This Disequilibrium?
Suspect disequilibrium if:
| Feature |
Disequilibrium pattern |
| Context |
Dizziness only when walking or standing; absent when lying down |
| Quality |
Sense of imbalance, unsteadiness — NOT spinning, NOT near-faint |
| Exam |
Gait disturbance, signs of neuropathy, parkinsonism, or cerebellar dysfunction |
| Associated |
Falls, wide-based gait, leg weakness, sensory loss |
Common causes:
- Peripheral neuropathy
- Parkinson's disease / parkinsonism
- Cerebellar disease (also look for dysarthria, gaze-evoked nystagmus, limb dysmetria)
- Cervical spondylosis / cervical myelopathy
- Drug toxicity
- Visual impairment (worsens any balance disorder)
→ If disequilibrium: neurologic examination + gait observation; targeted investigation for underlying cause
Step 5 — Nonspecific Dizziness
Consider if: dizziness does not fit the above patterns cleanly — vague "I'm just dizzy," no reproducible trigger, often in young healthy patients without neurologic or cardiovascular disease.
Common causes:
- Anxiety, panic disorder, depression (primary cause in ~25% of nonspecific dizziness)
- Hyperventilation (confirm by asking patient to hyperventilate; if dizziness reproduced AND no nystagmus appears, likely psychogenic)
- Medication side effects — especially antidepressants, anticonvulsants, anticholinergics, antihypertensives
- Hypoglycaemia or other metabolic disorders
- Post-head trauma / whiplash (provoked by visual stimuli — malls, scrolling screens, patterned environments)
- Milder forms of vestibular or presyncope not meeting full criteria
⚠️ If hyperventilation reproduces dizziness AND nystagmus appears: this is a vestibular lesion unmasked by hyperventilation — NOT psychogenic.
→ If nonspecific: medication review, metabolic screen, consider psychiatry assessment if anxiety/depression features present
Clinical Guardrails
- Don't over-rely on the word "spinning" — cardiac patients with presyncope can describe a spinning sensation; vestibular patients may never say spinning.
- "Constant for months" ≠ vestibular — the CNS compensates for vestibular lesions. Months of constant dizziness is almost always psychogenic, metabolic, or multifactorial.
- Older patients are multifactorial — up to 44% of dizzy patients ≥65 have more than one cause. Screen for: anxiety, depression, impaired balance, past MI, postural hypotension, polypharmacy (≥5 drugs), hearing impairment.
- Always check medications — antihypertensives, antidepressants, anticonvulsants, and anticholinergics are common contributors and are often remediable.
Source: Barton JS. "Approach to the patient with dizziness." UpToDate. Last updated Dec 11, 2025.
1---2name: dizziness-type-classifier3description: Classifies a patient's dizziness into one of four categories — vestibular/vertigo, presyncope, disequilibrium, or nonspecific — using history, timing, triggers, and associated symptoms. Use when a patient presents with dizziness, giddiness, lightheadedness, feeling off-balance, spinning, or nearly blacking out and you need to determine the type before further workup.4---56# Dizziness Type Classifier78## Step 1 — Anchor to History, Not Symptom Quality910> Do NOT rely on whether the patient says "spinning" vs "lightheaded." Many patients describe their dizziness inconsistently, and symptom quality alone is unreliable. Instead, focus on **timing, triggers, and associated symptoms**.1112Ask:13- When does it happen? (standing, lying down, head movement, out of the blue)14- How long does each episode last? (seconds, minutes, hours, constant)15- What makes it worse?16- What other symptoms come with it?1718---1920## Step 2 — Is This Vestibular / Vertigo?2122**Suspect vestibular if ALL of the following:**2324| Feature | Vestibular pattern |25|---|---|26| Trigger | Head movement makes it worse (patient afraid to move) |27| Duration | Episodes last seconds to hours; NOT continuously present for months |28| Quality | Spinning, whirling, tilting — but vague descriptions do NOT exclude it |29| Exam | Nystagmus present (or Dix-Hallpike positive) |30| Associated | Nausea, postural instability |3132> ⚠️ Constant dizziness lasting months is usually NOT vestibular — central adaptation corrects vestibular lesions within weeks.3334**Triggers that point to vestibular:**35- Rolling over in bed, bending neck back, lying down → positional vertigo (BPPV)36- Head motion in any direction → vestibular disorder (all vestibular dizziness worsens with head movement)37- Coughing, sneezing, Valsalva → superior canal dehiscence or perilymphatic fistula3839→ **If vestibular: proceed to Peripheral vs Central Vertigo Differentiator**4041---4243## Step 3 — Is This Presyncope?4445**Suspect presyncope if:**4647| Feature | Presyncope pattern |48|---|---|49| Trigger | Upright posture (standing or seated); NOT lying down |50| Quality | "Nearly blacking out," feeling of impending faint, warmth, pallor, visual greyout |51| Duration | Seconds to minutes |52| Associated | Diaphoresis, nausea, palpitations, chest discomfort, dyspnoea |53| History | Cardiac disease, dehydration, antihypertensives, antidepressants |5455> ⚠️ If dizziness occurs while lying down, think cardiac arrhythmia — not orthostatic hypotension.5657**Subtypes to consider:**58- **Orthostatic hypotension** — occurs on standing; confirm with BP/pulse lying → standing (≥20 mmHg systolic drop)59- **Cardiac arrhythmia** — occurs lying or sitting; palpitations may be present60- **Vasovagal** — triggered by pain, emotion, prolonged standing6162→ **If presyncope: evaluate as syncope (orthostatic vitals, ECG, cardiac history)**6364---6566## Step 4 — Is This Disequilibrium?6768**Suspect disequilibrium if:**6970| Feature | Disequilibrium pattern |71|---|---|72| Context | Dizziness only when walking or standing; absent when lying down |73| Quality | Sense of imbalance, unsteadiness — NOT spinning, NOT near-faint |74| Exam | Gait disturbance, signs of neuropathy, parkinsonism, or cerebellar dysfunction |75| Associated | Falls, wide-based gait, leg weakness, sensory loss |7677**Common causes:**78- Peripheral neuropathy79- Parkinson's disease / parkinsonism80- Cerebellar disease (also look for dysarthria, gaze-evoked nystagmus, limb dysmetria)81- Cervical spondylosis / cervical myelopathy82- Drug toxicity83- Visual impairment (worsens any balance disorder)8485→ **If disequilibrium: neurologic examination + gait observation; targeted investigation for underlying cause**8687---8889## Step 5 — Nonspecific Dizziness9091**Consider if:** dizziness does not fit the above patterns cleanly — vague "I'm just dizzy," no reproducible trigger, often in young healthy patients without neurologic or cardiovascular disease.9293**Common causes:**94- Anxiety, panic disorder, depression (primary cause in ~25% of nonspecific dizziness)95- Hyperventilation (confirm by asking patient to hyperventilate; if dizziness reproduced AND no nystagmus appears, likely psychogenic)96- Medication side effects — especially antidepressants, anticonvulsants, anticholinergics, antihypertensives97- Hypoglycaemia or other metabolic disorders98- Post-head trauma / whiplash (provoked by visual stimuli — malls, scrolling screens, patterned environments)99- Milder forms of vestibular or presyncope not meeting full criteria100101> ⚠️ If hyperventilation reproduces dizziness AND nystagmus appears: this is a vestibular lesion unmasked by hyperventilation — NOT psychogenic.102103→ **If nonspecific: medication review, metabolic screen, consider psychiatry assessment if anxiety/depression features present**104105---106107## Clinical Guardrails108109- **Don't over-rely on the word "spinning"** — cardiac patients with presyncope can describe a spinning sensation; vestibular patients may never say spinning.110- **"Constant for months" ≠ vestibular** — the CNS compensates for vestibular lesions. Months of constant dizziness is almost always psychogenic, metabolic, or multifactorial.111- **Older patients are multifactorial** — up to 44% of dizzy patients ≥65 have more than one cause. Screen for: anxiety, depression, impaired balance, past MI, postural hypotension, polypharmacy (≥5 drugs), hearing impairment.112- **Always check medications** — antihypertensives, antidepressants, anticonvulsants, and anticholinergics are common contributors and are often remediable.113114---115116*Source: Barton JS. "Approach to the patient with dizziness." UpToDate. Last updated Dec 11, 2025.*
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