Dizziness, vertigo, and presyncope:

Whats the difference?

Abstract: Dizziness is a general term used to express subjective patient complaints related
to changes in sensation, movement, perception, or consciousness. There are four types of
dizziness: vertigo, disequilibrium, presyncope/syncope, and dizziness as a result of psychological
disturbances. Differentiating the type of dizziness will assist in the course of the evaluation.

izziness is a general term frequently used to

express vague, subjective complaints. Patients
complaining of dizziness use unclear words to
describe the feelings related to the changes in sensation,
movement, perception, or consciousness.1,2 Dizziness itself
can have multiple causes and is one of the most frustrating symptoms to diagnose. Initially, differentiating the
type of dizziness will assist in the course of the evaluation.

Dizziness can be identified as one of four types: vertigo,

disequilibrium, presyncope/syncope, and dizziness as a
result of psychological disturbances.
Classification of dizziness
Vertigo
Vertigo implies a change in motion related to ones self or
the environment.3,4 Some common complaints of dizziness

Key words: disequilibrium, dizziness, lightheadedness, presyncope, syncope, vertigo

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Photo by svetikd/istockphoto

By Scott J. Saccomano, PhD, GNP-BC, RN

Dizziness, vertigo, and presyncope: Whats the difference?

include spinning, tilting, feeling unbalanced, twirling, or a

back-and-forth motion.3,5,6
Disequilibrium
Disequilibrium is characterized by shakiness or instability
when ambulating. It can be related to neurologic impairment such as a neurologic lesion, gait disorder, neuropathy,
or Parkinson disease.5,7,8
Presyncope/syncope
Presyncope is a sensation of lightheadedness or the feeling of
imminent fainting that precedes a syncopal episode.9,10 Syncope is defined as a transient loss of consciousness related to
cerebral hypoperfusion or cardiac irregularities.
Psychological disturbances
Psychological disturbances such as anxiety, panic attacks,
depression, or the pharmacologic measures used to treat
these disorders may also result in dizziness.11,12 The dizziness is not clearly defined and is not related to positional
changes and orthostatic hypotension. There is no significant
history of cardiac disease or medical conditions that produce
sensory defects.11,12
Epidemiology
Dizziness is one of the most common primary care office
complaints with almost 58% of patients over 45, and 44% of
patients under 45 reporting vertigo or dizziness.5,13 Dizziness
affects approximately 20% to 30% of the general population
and has a personal impact that interrupts daily activities, accounts for increased use of sick leave, and increased medical
consultation.15 Complaints of vertigo and dizziness related to
anxiety are more prominent in patients under age 45 (approximately 8.5%) and tend to decrease with age (approximately
2%).13 Only 3% of the population complains of dizziness or
vertigo related to medication intake.13 Vestibular dizziness
is the cause in approximately 50% of cases.5 Dizziness and
vertigo account for approximately 1% of ED visits and 2%
to 3% of hospital admissions.14 The overall cost of care for
treating patients with balance disorders is over $1 million, and
the patient-care cost for balance disorder-related falls is more
than $8 billion per year.5,14-16
Pathophysiology
Vertigo
The primary causes of vertigo are related to the peripheral nervous system (common) or central nervous system
(uncommon).4 Disorders of the inner ear or labyrinth system are the most common cause of peripheral vertigo.6
Vertigo results from an impairment in the ears vestibular
system pathway. This pathway controls balance and eye
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movements, resulting in sensory overload and impaired

cortical integration, causing the brain to misinterpret
sensory data.1,3,17 Central causes of vertigo (or uncommon vertigo) include some underlying medical disorder.
Disorders such as cerebrovascular disease, brainstem
lesions, and demyelinating diseases (multiple sclerosis)
are the most common causes of central vertigo and require
a complete workup to determine the actual cause.18 Vertigo
associated with vestibular problems is classified as peripheral or central. Peripheral or common causes of vertigo
are usually a result of disturbances of the inner ear that
affect the labyrinth or the vestibular nerve.3,6 Some of the
common causes of peripheral vertigo can include labyrinthitis, benign positional vertigo, and Mnire disease.4,9
Included in the causes of central or uncommon vertigo are
the diagnoses of migraine headaches, multiple sclerosis, and
possible tumors.4
Disequilibrium
Disequilibrium, or unsteadiness related to postural control,
is primarily related to neurologic disorders in the absence
of vestibular impairment.6 In addition, disequilibrium can
be related to sensory or proprioception defects. Disequilibrium is multisensory and can be related to peripheral
neuropathies, visual impairments, musculoskeletal disorders
affecting gait, and arthritis spondylosis. The most common
cause of disequilibrium is multisensory deficits.7,8
Presyncope/syncope
The primary causes of presyncope/syncope are cerebral
hypoperfusion or cardiac irregularities. Cerebral hypoperfusion can produce a transient loss of consciousness with
a quick recovery time. Syncope, which is cardiac in nature,
can result from one of two types of disorders: structural
disorders of the heart (such as a stenosis) and electrical
dysfunction (such as dysrhythmias).10,19 Common causes
of cardiac syncope are bradycardia and tachydysrhythmias, which decrease circulating blood volume, leading
to decreased cardiac output causing syncope.20 The most
common causes of cerebral hypoperfusion causing syncope include vasovagal syncope, vascular events such as
stroke, transient ischemic attack (TIA), migraine headaches, and hyperventilation.21 Other less frequent causes
of syncope include seizures, hypoglycemia, and anxiety.5,20
The following medical conditions are associated with the
syncopal feelings of lightheadedness or fainting: cardiac
irregularities such as mitral valve prolapsed, sick sinus
syndrome, aortic stenosis, and heart block.20,22 Vascularrelated presyncope/syncope is associated with conditions
such as dehydration, hypotension, cough, and the Valsalva
maneuver.21,23
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Dizziness, vertigo, and presyncope: Whats the difference?

Psychological disturbances
The cause of the dizziness is unknown, but it is believed
to be related to or induced by psychological disturbances
such as reactive anxiety, depression, or the medications used
to treat the disorders. Dizziness occurs in the absence of
physical illness but occurs in the presence of a psychiatric
condition. In addition, respiratory alkalosis, a byproduct of
hyperventilation seen in many of these psychological states,
can have patients reporting lightheadedness.11,12

a state of lightheadedness or a feeling of imminent loss

of consciousness. The feeling of lightheadedness is often
reported in conjunction with associated symptoms such
as nausea, diaphoresis, and weakness and can present with
transient loss of consciousness or blackout.20,23 The actual transient blackout can be accompanied with visual
changes and lack of awareness of surroundings.10 The patient history reveals that symptoms worsen when standing
and are relieved when lying down.27

Clinical presentation
Dizziness is very difficult to describe, as it is subjective.
Since dizziness is somewhat of a global term, it is important
to obtain a thorough history that can assist in the differentiation of the type of dizziness the patient is experiencing. During the course of the history, it is important to
remember not to lead the patient with questions such as
is the room twirling or are you spinning? The interview
should begin with broad opening questions or statements:
describe what you mean by dizziness or can you describe
your dizziness? Using broad, open-ended statements allows
the patient to describe the sensation or what the dizziness
feels like to them. Once the nurse practitioner is able to
establish the basis of the complaint, further assessment
should be directed at characterizing the type of dizziness,
the timing of the individual events, precipitating factors, and
alleviating/associated factors. Patient complaints related to
dizziness include reports of I feel like I am going to faint
(presyncope), I might fall (disequilibrium), the room is
spinning (vertigo), I feel like I am spinning, or simply,
I am just dizzy. These previous complaints of dizziness
warrant a history that should focus on the neurologic and
cardiovascular systems, medication history, and functional
assessment.5,6,24
The complaint of vertigo yields such descriptions as
spinning, twirling, rotating, and swaying.4 The distinguishing characteristic between true vertigo and dizziness is
that vertigo is related to a sensation of motion and is often
exaggerated with movement.3 Associated symptoms that
are frequently reported with vertigo are nausea, diaphoresis, vomiting, vision changes (such as blurred vision
or diplopia), and disequilibrium.4,13 Ear symptoms with
vertigo include such symptoms as tinnitus, pain or pressure in the ear, or changes in hearing.17,25 Disequilibrium
is characterized by shakiness or a sense of imbalance with
ambulation;7 patients may report dizziness when in actuality, they feel unsteady on their feet.6,8 The sense of imbalance with disequilibrium worsens with darkness and can
change the length and width of steps with ambulation.7,26
Patients may report a new use of a cane or using furniture
for contact guarding during ambulation.6 Presyncope is

History/physical exam
The examination of a patient with complaints of dizziness,
vertigo, or presyncope/syncope should begin with a
thorough medical history. The history obtained will guide
the interview to focus on the specific patient complaints:
Have the patient describe the sensation(s) he or she is
experiencing. What is meant by the word, dizziness?
Based on the responses, determine which category of
dizziness the patient is experiencing.
Assess the symptoms: when does it begin? How often
does it occur? What makes it better? What makes it worse?
Determine the severity of the symptoms.
Evaluate for any associated symptoms such as nausea,
vomiting, tinnitus, or ear infections.
Assess for associated neurologic symptoms such as
diplopia, paralysis, paresthesia, dysphagia, confusion,
and head injury. Do you experience headaches?
Assess for associated cardiac symptoms such as palpitations, shortness of breath, and chest pain. Did this occur
after exercise? Did this occur when you changed positions?
Evaluate past medical history for cardiac disease, stroke,
TIA, toxic exposure, dysrhythmia, diabetes, hyperlipidemia, hypertension, or history of falls.
Inquire about any recent illness such as viral infection,
upper respiratory infection, or ear surgery.
Take a medication history including all over-the-counter
medications and adjuvant therapies.
Evaluate psychological factorswould they describe
themselves as nervous or anxious?9,24,28-30
A neurologic exam is necessary to assess cognition.
Particular attention should be given to cranial nerves III,
IV, and VI for eye movements, cranial nerve II for evaluation of visual acuity, and evaluation of cranial nerve VIII
for nystagmus. Cranial nerves III, IV, and VI must work
together in concert; if they do not, diplopia can result
leading to dizziness. Visual acuity cranial nerve II can be
impaired and cause temporary episodes of imbalance.
Impairment or dysfunction of cranial nerve VIII is often
the cause vertigo related to vestibular disease. After the
cranial nerve assessment, the neurologic exam continues
with muscle strength, tone, coordination, and reflexes. The

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Dizziness, vertigo, and presyncope: Whats the difference?

adjunct to the ENG.37 Rotational testing stimulates the

musculoskeletal system is evaluated for gait and balance as
well as stride for general disequilibrium. Standing balanced
labyrinth system to evaluate eye movements, nystagmus,
should be assessed with eyes open and closed (Rombergs
and gaze. During the rotational test, the patient sits in
test).5,20 Rombergs test evaluates vestibular function and
a computer-controlled chair in a darkened booth while
the eye movements, nystagmus, and gaze are recorded
the test is positive if the patient is unsteady or sways only
as the chair is turned; results measure the symmetry and
with eyes closed.
intensity of the patients eye movement.38
Otoscopic exam should include a pneumatic otoscope evaluation, hearing exam, and the Weber and Rinne
A second method of vestibulospinal evaluation is
test.24,25,31 Pneumatic otoscope exam can assess for the presposturography, or measurement of postural sway/balance; it
is indicated when patients complain of dizziness and vertigo.
ence of fluid or infection that may indicate serous otitis
During this procedure, the patient is standing on a platform
media. Sensorineural hearing loss is present in Mnire
that is mechanically altered to vary the proprioceptive and
disease, labyrinthitis, and acoustic neuroma.
visual cues. Posturography measures the eyes response under
A cardiac exam includes evaluation of heart rate, rhythm,
six different sensory conditions, and its results include inforheart sounds, carotid bruits evaluation, and BP monitoring
mation regarding balance, presence of lesions, and whether it is
in both the supine and standing positions to assess for orthostatic changes. An ECG can identify the
underlying causes of cardiac syncopal
episodes and correlate symptoms with
A positive Dix-Hallpike test shows a
a dysrhythmia.20
burst of rotational nystagmus indicating
A neuro-otologic exam is a general
benign positional vertigo.
term to identify specific exam procedures for complaints of vertigo and disequilibrium. These procedures are used
vestibular or not; it is useful in rehabilitation interventions.8,39
to evaluate vertigo and disequilibrium to differentiate between causes of peripheral or central origin. The diagnostic
The results are compared with age-related norms.
procedures that are used to evaluate the vestibuloocular and
Frenzel glasses (or goggles) are a combination of
vestibulospinal reflex responses are identified below.3,6,8,17,31,32
illumination and a lens of +20 magnification; these glasses
are used to evaluate patients with vestibular disorders. The
It is also important to note hydration status as signs and
Frenzel glasses are placed on the patient, the room is darksymptoms of dizziness need not indicate a disease process, it
ened, and the magnification does not allow the patient to
simply can be the need for more water, as dizziness is an early
have a fixed focus. As the eyes are well-lit and magnified,
sign of dehydration. This may be evident in active individuals
nystagmus can be easily seen in patients with central or
who play sports, patients on a strict fluid restriction, in indiperipheral deficits.40
viduals who use diuretics, or patients with diabetes who are active. In these instances, additional fluids or adjustments to the
The Dix-Hallpike maneuver is done to diagnose benign
fluid intake, diuretics, or medications may be indicated.29,33,34
paroxysmal positional vertigo (BPPV), which is one of the
most common causes of vertigo;5 the maneuver is designed
to produce nystagmus. The patient is placed in a seated
Diagnostic testing
position, the head is rotated 45 degrees to the side (to stimuVestibular lab testing is used to supplement the history
late the semicircular canal while supporting the patients
and physical exam findings. Lab studies include
head), and the patient is put in a supine position with the
electronystagmography (ENG), rotational testing, and
head hanging off the edge of the exam table at 45 degrees;
posturography. Vestibular testing is used to differentiate
this is repeated in the other ear. A positive Dix-Hallpike test
peripheral lesions from central lesions and lateralization
shows a burst of rotational nystagmus indicating benign
confirmation.25,35,36 If a vestibular lesion is suspected, ENG
positional vertigo; if it is negative, it is less likely that BPV
is used for evaluation; ENG measures the amount of nysshould be considered as a diagnosis.24,36,40
tagmus through the use of electrodes positioned around
the eyes. A variety of measures are recorded: positions
Audiology testing is used as an adjunct to confirm or
of gaze and caloric/positional testing. Negative results
eliminate a specific diagnosis. Diseases associated with verindicate smooth eye movements when tracking an object,
tigo frequently have hearing loss associated with them. The
while abnormal results indicate involuntary eye moveuse of audiological testing can assist with the presence or
ments.37 In addition, rotational testing evaluates vestibular
absence of hearing loss, which can also confirm or exclude
diagnosis. A routine audiological exam can measure tone
function or the vestibuloocular response; it is used as an
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Dizziness, vertigo, and presyncope: Whats the difference?

frequencies and word recognition. The Weber and Rinne

tests can be used to evaluate for sensorineural or conductive hearing loss.41
Neuroimaging should be considered for patients with
neurologic risk factors, neurologic signs and symptoms
such as stroke, the possibility of brain/central nervous
system lesions of the labyrinth/canal, or infection.24,41 When
vertebrobasilar insufficiency is suspected, magnetic resonance angiography can be ordered.21 CT scan or MRI can
be ordered based on suspicion of findings in the neurologic
exam.20,42
For patients who have underlying cardiac disease
or a suspicion of cardiac involvement, an ECG should
be ordered. If dysrhythmias are suspected, Holter
monitoring or ambulatory telemetry monitoring can be
implemented. Vital signs should be taken as an adjunct
to these diagnostic tests in sitting and standing positions

to assess for orthostatic changes. Lastly, an echocardiogram (if warranted) should be conducted to further assess
cardiac status for evidence of structural cardiac changes.9,23
Dizziness, fainting, and syncope are not routine symptoms of seizures. However, an electroencephalogram (EEG)
should be included in the diagnostic testing if epilepsy is
suspected as the cause of syncope. The EEG testing should
be done under the guidance of a neurologist.20
Routine lab testing should be completed to evaluate for
any comorbid conditions.35 Initially, lab tests do not identify
the cause of syncope or dizziness. In fact, less than 1% of
the causes of dizziness are identified by lab testing. Lab tests
such as electrolytes, thyroid hormones (thyroid-stimulating
hormone, T3, T4, thyroid antibody tests), complete blood
count, glucose, and creatinine may be useful when patients
report or exhibit symptoms that may indicate comorbid
disease.24

Differential diagnosis of dizziness3-5,14,17,22,23

System

Cause

Description

Cardiovascular

Lightheadedness, changes in BP and pulse, may

have history of heart disease

Dysrhythmias (fast or slow rate)

Orthostatic hypotension
Hypovolemia or anemia
Myocardial ischemia
Structural cardiac or valvular disease
Hypoxia
Vasovagal episode (also neurologic)

NeurologicOtologic
Peripheral vestibular
causes

Benign paroxysmal positional

vertigo

Position changes cause transient vertigo, no

tinnitus, hearing loss, nausea, vomiting

Labyrinthitis
Vestibular neuritis

Vertigo, tinnitus, hearing loss following

upper respiratory event

Mnire disease

Fullness in the ear, loss of hearing, tinnitus and

vertigo unrelated to position changes

Vertebrobasilar ischemia
Cerebellopontine angle mass

Other brainstem defects in association with vertigo,

diplopia, focal and sensory motor deficits

Multiple sclerosis

Demyelinization

Basilar artery migraine

Headaches, visual aura, tinnitus, diplopia, ataxia,

decreased hearing

Drug effects

Adverse reaction to medications that cause

vertigo and dizziness

Psychiatric

Hyperventilation
Anxiety
Depression
Agoraphobia

Central vestibular
causes

Other
Antiepileptic drug
Antihypertensives
Aminoglycosides
Oral diabetes agents and insulin
Antipsychotic
Sedative/hypnotics
Alcohol

50 The Nurse Practitioner Vol. 37, No. 12

Dizziness is not well defined and is not

positional, no cardiac or ocular disease

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Dizziness, vertigo, and presyncope: Whats the difference?

Differential diagnosis
Differentiating the diagnosis begins with clarifying the
category of dizziness (see Differential diagnosis of dizziness).
Vertigo arises from multiple etiologies. Initially, it should
be determined if the patient is experiencing peripheral
or central vertigo. Peripheral vertigo, inner ear, or cranial
nerve III problems include vestibular neuritis, labyrinthitis, benign positional vertigo, and Mnire disease. These
conditions present with an increased presence of nausea,
a negative neurologic exam, and position-related changes.
Central vestibular causes generally involve the cerebellum
and brainstem and include such disorders as vertebrobasilar
ischemia, cerebellopontine angle mass, multiple sclerosis,
and basilar artery migraine. Classic symptoms of central
vestibular disorders include associated neurologic findings
and/or vertigo that is not position related.3-5,24,25
Evaluating disequilibrium at times is clear based on history.
However, at other times, it can be inexact or unclear, but suggest balance problems rather than actual dizziness. In the
absence of dizziness and a description of balance impairment,
the evaluation shifts to multifactorial impairment, particularly visual and peripheral sensory function. Disequilibrium
must be differentiated from complaints of visual symptoms
or psychological causes. Examples of mutlifactorial causes of
disequilibrium include diabetes mellitus, drug toxicity, cerebellar disorders, extrapyramidal symptoms, and possible tumors.8
The most common symptom that indicates cardiovascular involvement is lightheadedness. Patients may complain
of lightheadedness, the pulse may increase and the BP may
drop. Diagnostic cardiac exam should include evaluation for
cardiac dysrhythmias, structural cardiac defects, vasovagal
response, and orthostatic hypotension.21
Treatment
Identifying any positive neurologic or cardiac signs and
symptoms that lead to a suspicion of underlying disorders
should generate prompt referral. For many patients with
vestibular disorders, vestibular rehabilitation is the prime
intervention; it can be used in conjunction with progressive
physical activity.8,43 Vestibular rehabilitation is an intervention for dizziness, it is a group of specialized exercises that increase awareness in the other senses. This treatment develops
the patients compensation in gaze, motor control, and posture. The goal is to increase balance, decrease dizziness, and
improve functional activities.8,39 The use of medication in
the treatment of vestibular disorders is limited.
Medication use for the treatment of vestibular disorders
is aimed at treating associating factors such as nausea, vomiting, and anxietythe indication of the drugs is based on the
confirmed diagnosis. Vestibular suppressant drugs from the
following drug classes are the most common:44
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Benzodiazepines act to suppress vestibular responses.

Medications include lorazepam, clonazepam, and
diazepam.
Anticholinergics increase motion tolerance. Medications include scopolamine and zamifenacin (under investigation).44
Antihistamines control in the vestibular system is unclear. It
is thought that antihistamines reduce and prevent motion
sickness. The most frequently administered antihistamines
are promethazine and meclizine. Some antihistamines
produced antiemetic results as well.
Antiemetics are commonly used for vestibular lesions that
produce nausea. Medications include prochlorperazine
and promethazine.
Vestibular suppressants and antiemetics are the primary
drugs of choice for the treatment of vertigo.44
The practitioner should exercise caution when prescribing these medications for older adults. The adverse reactions
of the medication (primarily the anticholinergics) include
drowsiness, changes in mental status, and urinary retention.
Caution should be used with the benzodiazepines as they
have the possibility for dependence.45 When psychological
etiologies are suspected, atypical manifestations and other
causes must be excluded. Dizziness of psychological origin
is ill-defined, not positional, and there is no evidence of
cardiac or ocular disease. Possible causes of dizziness with
psychological origin include anxiety, agoraphobia, hyperventilation, and depression.12
Using the history and physical exam findings, underlying suspicions may require prompt evaluation by
a neurologist or cardiologist and could possibly require
evaluation in the ED or hospitalization. If diagnosis is
unclear, specialty evaluation may be necessary. Cases that
involve disequilibrium or vertigo should be referred to
an otoneurologist or otolaryngologist for further testing
such as vestibular lab testing. In some cases, an adjustment
to medications or physical therapy treatment program
may be indicated. Patients with vestibular dysfunction
or disequilibrium should be referred for physical therapy
or vestibular rehabilitation. A previously stable cardiac
condition where a change is noted requires immediate
attention.
Education of the patient should include information regarding the diagnostic procedures to determine the etiology
of dizziness, vertigo, presyncope/syncope, or disequilibrium
(see Patient education). Once a diagnosis is confirmed,
the patient should be given specific information regarding prognosis, treatment plan with options, and potential
complications. When a program of vestibular rehab is instituted, patients should be instructed that initially, symptoms
may worsen; as the program continues, the symptoms will
diminish. Specific attention to the medication regimen,
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Dizziness, vertigo, and presyncope: Whats the difference?

Patient education46
Stay alert to the possibility that you may lose your
balance to prevent falls or injuries.
Use an assistive device such as a walker or cane if needed.
Sit down when you feel dizzy.
Change positions slowly.
Do not drive a car or operate heavy machinery when
you feel dizzy.
Use home modifications to increase safety:
keep walkways clear of clutter, use nightlights, remove
scattered rugs, use non-slip mats in the bathtub.
Seek help if there is sudden onset of weakness,
paresthesia, diplopia, trouble speaking, chest pain,
or fainting that accompanies vertigo/dizziness.
Avoid rapid movements of the head.
Limit the use of products that can impair circulation
such as caffeine, alcohol, and tobacco.

administration procedures, and potential adverse reactions

should be communicated to the patient.
The Vestibular Disorders Association (VEDA) is a
national organization that assists and provides support to
individuals with dizziness and balance disorders. Patients
should be encouraged to contact them at (800) 837-8428,
or visit them online at www.vestibular.org.
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Scott J. Saccomano is an assistant professor at the Herbert H Lehman College,
Department of Nursing in Bronx, NY.
The author has disclosed that he has no financial relationships related to this article.
DOI-10.1097/01.NPR.0000422206.92550.5b

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