Symptom terminology

By Marcello Cherchi, MD PhD

Definition of “vertigo,” “dizziness,” etc.

Countless articles have been written in an attempt to define what is meant by the terms “vertigo,” “dizziness,” etc. in the context of clinical medicine (Bisdorff, Von Brevern et al. 2009). Although these terms and their attempted definitions have been perpetuated in medical training programs for decades, it has been shown repeatedly that there is no one-to-one correspondence between a particular term and a specific diagnosis (Kerber and Newman-Toker 2015; Newman-Toker and Edlow 2015; Stanton et al. 2007). The 306 practicing otologists who responded to a questionnaire on the definition of the term “vertigo” provided answers that led the authors to conclude that, “The meaning of the word vertigo is imprecise and variable” (Blakley and Goebel 2001). Nevertheless, Newman-Toker and Edlow (2015) offer the following definitions:

• Dizziness is the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion. This includes sensations sometimes referred to as giddiness, lightheadedness, or nonspecific dizziness but does not include vertigo.
• Presyncope (also near-syncope or faintness) is the sensation of impending loss of consciousness. This sensation may or may not be followed by syncope. When patients report “lightheadedness,” it should be classified as presyncope, dizziness, or both.
• Syncope (also faint) is transient loss of consciousness due to transient global cerebral hypoperfusion characterized by rapid onset, short duration, and spontaneous complete recovery. Syncope usually leads to loss of postural control and falling.
• Vertigo is the sensation of self-motion (of head/body) when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement.
• Unsteadiness is the feeling of being unstable while seated, standing, or walking without a particular directional preference. This sensation has previously been called disequilibrium or imbalance.

Despite the lack of a one-to-one relationship between a diagnosis and a subjective symptom description, there have been a number of attempts to develop purely questionnaire-based diagnostic mechanisms (Gavilan, Gallego et al. 1990, Feil, Feuerecker et al. 2018, Jacobson, Piker et al. 2019), and while these may serve as helpful screening or triage tools (such as in primary care settings), both patients and their referring physicians expect a more confident diagnosis when they refer to a subspecialty clinician.

Thus, in practice, while we still place importance on taking a good clinical history, we find these descriptive terms in themselves to be of limited utility in arriving at a diagnosis. Our experience is that the symptom’s chronology (whether it is constant or episodic; its frequency and duration), its triggers, the factors that worsen or improve the symptom, and any associated symptoms, are much more likely to aid a clinician in narrowing the differential diagnosis, and in this regard we agree with Dr. Newman-Toker and colleagues (Newman-Toker and Edlow 2015). When pressed to use a term, we prefer “disequilibrium,” as this word is sufficiently general to feel rather neutral for most people.

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