Dizziness History Taking – OSCE Guide

Dizziness is a common presenting complaint in both general practice and the emergency department. It can be challenging to obtain a history with this presentation because the term ‘dizziness’ and other commonly used expressions (e.g. ‘funny turn’) can mean different things to different people.
This makes it easy for the patient and clinician to misunderstand each other, leading to the risk of diagnostic error. It is essential to ask the patient to be as specific as possible about what they have experienced, using open and closed questions.
Whilst many patients who experience dizziness will have a non-serious cause, it is important not to miss a serious cause requiring urgent recognition and treatment.
Although this article only covers history taking, a full patient assessment will always include a focused physical examination to aid the distinction between different aetiologies of dizziness.
For this OSCE guide, dizziness has been divided into vertigo and non-vertiginous dizziness. This is because there are some questions which are very specific to vertigo. However, it is important to know that patients may experience more than one type of dizziness.
Download the dizziness history taking PDF OSCE checklist, or use our interactive OSCE checklist. You may also be interested in our HINTS examination guide.

Background
Vertigo
Vertigo is defined as the sensation of motion (most typically rotation) when the person is not moving or a distorted sensation of motion during otherwise normal head movement.
Vertigo is a symptom which arises as a result of dysfunction in the vestibular system. The causes of vertigo can be divided into those originating in the inner ear or the vestibular nerve (‘peripheral vertigo’) and those originating in the brain or brain stem (‘central vertigo’).1
Although most patients with vertigo will have a peripheral cause, it is essential not to miss the diagnosis of a central pathology.
Central vertigo
Vascular causes of central vertigo include:

Posterior circulation stroke: causes hyper-acute (within seconds) onset of continuous vertigo, which may be so severe that the patient cannot stand unaided. Although vertigo is the most common symptom (and may be the only symptom), additional neurological symptoms, including occipital headache, increase the possibility of this diagnosis.2
Vertebrobasilar insufficiency: transient ischaemia in the anterior inferior cerebellar artery (AICA) distribution, usually due to atherosclerosis. Typical presenting symptoms include episodic vertigo, lasting between 30 seconds and 15 minutes, diplopia, dysarthria, ataxia, drop attacks and clumsiness. Episodes are typically brought on by abruptly standing or turning the head.
Vertebral artery dissection: a cause of posterior circulation stroke in young adults, may be traumatic or spontaneous. Symptoms include headache, dizziness, and neck pain. Predisposing conditions include hypertension, Ehlers-Danlos syndrome, Marfan syndrome, osteogenesis imperfecta and fibromuscular dysplasia.3

Other causes of central vertigo include:

Multiple sclerosis (MS): can cause vertigo due to the development of demyelinating plaques in the vestibular pathways. Vertigo may be associated with diplopia and/or gait problems. MS can also cause peripheral vertigo.4
Posterior fossa tumour: in addition to vertigo, this condition may present with unilateral hearing loss or tinnitus.
Vestibular migraine: presents with vertigo along with typical symptoms of migraine, such as unilateral headache, photophobia and phonophobia. It is largely a diagnosis of exclusion, as it can mimic other causes of central vertigo.5

Peripheral vertigo
The most common causes of peripheral vertigo include:

Benign paroxysmal peripheral vertigo (BPPV): has a hyper-acute onset and is triggered by movement, typically turning over in bed. Patients describe short bursts (a few seconds to a minute) of intense vertigo. Repeated episodes are brought on by head movement. It is often associated with nausea, but not usually with vomiting, and there are no other accompanying symptoms. Patients may experience a residual sensation of much less severe disequilibrium for several hours afterwards, but this should not be confused with the persistence of the initial severe vertigo.
Ménière’s disease: classically consists of a combination of acute vertigo (spontaneous onset and lasts for minutes to hours) with unilateral aural fullness, tinnitus, and sensorineural hearing loss. Patients will experience repeated episodes of these symptoms with progressive hearing loss on the affected side.
Vestibular neuronitis/labyrinthitis: patients experience vertigo which comes on more gradually (usually over several hours), lasts for several days, and is made worse by movement.6 It may have a viral aetiology, and there may be preceding symptoms of an upper respiratory tract infection. Patients usually experience nausea and vomiting, and, in the case of labyrinthitis, there may be sensorineural hearing loss on the affected side.

Other causes of peripheral vertigo include:

Other otological conditions: otitis media with tympanic membrane perforation, cholesteatoma, Ramsay Hunt syndrome.
Medication side effects: aminoglycoside antibiotics such as gentamicin are vestibulotoxic and may cause vertigo.
Persistent postural-perceptual dizziness (PPPD): a functional neurological disorder that is thought to reflect a chronic vestibular system dysfunction. Patients may describe non-spinning vertigo or unsteadiness.7
Alcohol or substance misuse

Non-vertiginous dizziness
Patients who do not describe a sensation of movement associated with their dizziness are likely to have an alternative cause of their symptoms.
They may instead be experiencing a sensation of light-headedness, pre-syncope (a feeling of impending loss of consciousness), or disequilibrium (imbalance).
The two principal groups of causes of these types of dizziness are cardiovascular causes and neurological causes.8
Cardiovascular causes of dizziness
The reason for the dizziness is usually cerebral hypoperfusion. Cardiovascular causes of dizziness include:

Myocardial infarction
Cardiac arrhythmia
Acute left ventricular dysfunction
Pulmonary embolism
Orthostatic (postural) hypotension: the patient feels light-headed or pre-syncopal on moving from a lying or seated position to standing. This can be caused by either a failure of the normal peripheral vasoconstriction, which occurs on standing (seen, for example, in Parkinson’s disease), or by volume depletion (e.g. dehydration, sepsis, acute blood loss, metabolic abnormalities such as hyperglycaemia or hypernatraemia). 
Vasovagal pre-syncope (near-fainting): bradycardia and/or vasodilatation are triggered by parasympathetic activation, often in response to a trigger such as heat or prolonged standing. Syncope (fainting) can be averted by the patient recognising the symptoms and lying down, which increases venous return. 
Postural orthostatic tachycardia syndrome (POTS): typically affects young people, autonomic dysfunction causes postural dizziness and patients have inappropriate tachycardia on standing.

Neurological causes of dizziness
Neurological causes of dizziness include:

Normal pressure hydrocephalus: in this condition, the cerebral ventricles are enlarged, but intracranial pressure is normal. It is associated with ataxia, urinary incontinence, and impaired cognition.
Mal de debarquement syndrome: a persistent sensation of motion after, for example, a long boat or aeroplane journey.

Other causes of dizziness
Other causes of non-vertiginous dizziness include:

Hypoglycaemia
Drug-related: diuretics may cause volume depletion, whilst anti-hypertensives may cause orthostatic hypotension.
Alcohol
Carbon monoxide poisoning
Psychological: anxiety can cause dizziness, particularly if it is associated with hyper-ventilation. However, it is important to be aware that the experience of vertigo and other types of dizziness can be extremely anxiety-provoking. The patient’s symptoms should not be attributed to anxiety without considering all other potential causes.

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Opening the consultation
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Confirm the patient’s name and date of birth.
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.

General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include:

Demonstrating empathy in response to patient cues: both verbal and non-verbal.
Active listening: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and offering them a seat).
Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint
Use open questioning to explore the patient’s presenting complaint:

“What’s brought you in to see me today?”
“Tell me about the issues you’ve been experiencing.”

Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint if required:

“Ok, can you tell me more about that?”
“Can you explain what that pain was like?”

Open vs closed questions
History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.

History of presenting complaint
Gather further details about the patient’s dizziness using the SOCRATES acronym.
SOCRATES
The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. It is most commonly used to explore pain but can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.
Site
N/A
Onset
Clarify how and when the dizziness developed:

“When did the dizziness first start?”
“Did the dizziness start suddenly (over a few seconds)?”

The key here is to identify patients who have experienced a hyper-acute (over a few seconds) onset of their symptoms, which can be a marker of an acute vascular event (e.g. posterior stroke).
Character
Ask about the specific characteristics of the dizziness:

“Can you describe to me exactly what the dizziness is like?”

The key here is to distinguish vertigo from other types of dizziness.
True vertigo is a sensation of motion, usually rotation when the patient is still, and/or a sensation of abnormal motion accompanying normal head movement. Therefore, it is helpful to clarify this by asking:

“Did you feel as though you were moving, or the world was moving around you, even when you were still?”

If the patient struggles to answer this, it may be helpful to give them an example, such as:

“Did you feel like you had just stepped off a roundabout?”

If the patient has experienced true vertigo, they will probably recognise one or both of these descriptions.
Radiation
N/A
Associated symptoms
Ask if there are other symptoms which are associated with the dizziness:

“Are there any other symptoms that seem associated with the dizziness?” 

Time course
Clarify the time course of the dizziness, and whether it occurs in discrete episodes or is continuous:

“Does the dizziness come and go, or is it always there?”
“How long does each episode of dizziness last?”

Exacerbating or relieving factors
Ask if anything triggered the dizziness, and if anything makes it better or worse:

“What were you doing when the dizziness started?”
“Does anything make the dizziness worse?”
“Does anything make the dizziness better?”

It is particularly helpful to elicit whether there is a positional element to the dizziness.
Severity
Assess the severity of the dizziness by asking the patient to grade it on a scale of 0-10:

“On a scale of 0-10, how severe is the dizziness, if 0 is no dizziness and 10 is the worst dizziness you’ve ever experienced?”

After completing this initial information gathering, you should have established whether the patient is describing vertigo or non-vertiginous dizziness, the key characteristics of the problem, including onset, associated symptoms, timing, exacerbating and relieving factors and the severity.
Patients with vertigo
The SAFER mnemonic can help you reflect on the information you have gathered in the consultation and help you consider the potential diagnoses in a patient with vertigo:9

Serious causes of the presentation: if there are features in the history suggestive of any of the causes of central, vascular vertigo, then the patient is likely to require further investigation on an urgent basis.
Alternative causes of the presentation: posterior fossa tumours, vestibular migraine. Again, patients with features of these conditions will require urgent further investigation.
If you have not elicited specific features of conditions which are described in either of the first two categories, consider the information which you have gathered and ask yourself whether there are any features which do not fit with a non-serious, peripheral cause of vertigo. For example, are you considering a diagnosis of vestibular neuronitis, but the patient has described hyper-acute onset and has vascular risk factors?
Could this be an early or atypical presentation of a condition? For example, could vertigo be an unusual presentation of MS?
Are there red flags or risk factors for a serious condition? Red flags to look out for are listed below.

Red flags for a central cause of vertigo
In a patient with vertigo, the following red flags suggest a central cause:

Onset: hyper-acute onset (over a few seconds) may suggest a central vascular cause.
Associated symptoms: nausea and vomiting are common to all causes of vertigo and not helpful discriminators. However, the presence of other neurological symptoms may indicate a central cause. Particularly concerning are: headache, neck pain, acute hearing loss, facial or limb weakness, loss of sensation over the face or limbs, dysarthria, dysphagia, and visual symptoms such as diplopia.
Timing: Persistent vertigo is more concerning for a central cause than vertigo which has occurred in discrete episodes (although repeated episodes of vertebrobasilar ischaemia could present as a series of discrete episodes).
Exacerbating and relieving factors: In general, spontaneous onset vertigo is more concerning for a central cause than vertigo brought on by being in a particular position or by movement. However, there are exceptions to this, namely vertebrobasilar insufficiency, which can be triggered by neck movement and vertebral artery dissection, which can also be brought on by neck movement or trauma.
Severity: vertigo so severe that the patient cannot stand unaided is concerning for a central cause.
Presence of vascular risk factors: this makes a central vascular cause, such as posterior circulation stroke, more likely.10 Risk factors include: age >60; hypertension; hypercholesterolaemia; diabetes; current or ex-smoker and history of cardiovascular disease.

Patients with non-vertiginous dizziness
The SAFER mnemonic can also help you consider the potential diagnoses in a patient with non-vertiginous dizziness: 

Serious causes of the presentation: if there are features in the history suggestive of any of the cardiovascular or neurological causes of dizziness described above, this will require further investigation.
Alternative causes of the presentation: hypoglycaemia, medication side effects, carbon monoxide poisoning. Again, patients with features of these conditions will require urgent further investigation.
If you have not elicited specific features of conditions which are described in either of the first two categories, consider the information which you have gathered and ask yourself whether there are any features which do not fit with a non-serious serious cause of dizziness. It is especially important not to attribute dizziness to a psychological cause without full consideration of all of the other possibilities.
Could this be an early or atypical presentation of a condition? For example, could the dizziness be a presentation of silent myocardial infarction in a diabetic patient?
Are there red flags or risk factors for a serious condition? Red flags to look out for are listed below.

Red flags in patients with non-vertiginous dizziness
In a patient with dizziness (but not true vertigo), the following red flags suggest a more serious pathology:

Onset: hyper-acute onset (over a few seconds) may suggest an acute cardiovascular cause.
Associated symptoms: given the wide range of possible causes, many potential additional symptoms exist. Key symptoms to exclude include: chest pain, palpitations, shortness of breath, fever, visual disturbance, ataxia, cognitive problems.
Exacerbating and relieving factors: dizziness which is made worse by moving from lying or sitting to standing is suggestive of either volume depletion or autonomic failure. Symptoms brought on by exertion and relieved by rest may suggest an acute cardiovascular cause.
Presence of vascular risk factors: this makes a cardiovascular cause more likely. Risk factors include: age >60; hypertension; hypercholesterolaemia; diabetes; current or ex-smoker and history of cardiovascular disease.

Ideas, concerns and expectations
A key component of history taking involves exploring a patient’s ideas, concerns, and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation.
The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. This will help ensure your consultation is more natural, patient-centred, and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue:

“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

Concerns
Explore the patient’s current concerns:

“Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”

Expectations
Ask what the patient hopes to gain from the consultation:

“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?

Summarising
Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of the patient’s history and provides an opportunity for the patient to correct any inaccurate information.
Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far: “Ok, so we’ve talked about your symptoms, your concerns and what you’re hoping we achieve today.”
What you plan to cover next: “Next I’d like to quickly screen for any other symptoms and then talk about your past medical history.”

Systemic enquiry
A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.
Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.
Some examples of symptoms you could screen for in each system include:

Systemic: fever
Cardiovascular: chest pain, palpitations
Respiratory: shortness of breath
Gastrointestinal: vomiting or diarrhoea (possible causes of dehydration leading to cerebral hypoperfusion), gastrointestinal blood loss (haematemesis, melaena or fresh rectal bleeding)
Genitourinary: polyuria or polydipsia (suggestive of hyperglycaemia or hypercalcaemia). Menorrhagia is a possible cause of anaemia in female patients.
Neurological: sensory or visual disturbances
Musculoskeletal: limb weakness and joint pain can cause feelings of unsteadiness, as can loss of joint proprioception.

Past medical history
Ask if the patient has any medical conditions: 

“Do you have any medical conditions?”
“Are you currently seeing a doctor or specialist regularly?”

If the patient does have a medical condition, you should gather more details to assess how well-controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.
It is important to know whether the patient has experienced similar episodes of dizziness before and, if so, whether they have sought medical attention for them. This may be reassuring if they have previously been investigated and received a diagnosis such as vestibular migraine.
However, in this situation, it is essential to maintain an open mind about the current presentation. Firstly, they may be presenting now with a new condition. For example, a patient with a history of migraine may now have suffered a stroke. Secondly, the initial diagnosis may have been incorrect, and you may be able to correct it with the new information in front of you.

Examples of relevant medical conditions
A past medical history of particular relevance to dizziness includes:

Risk factors for vascular disease: age>60, hypertension, hypercholesterolaemia, diabetes, current or ex-smoker
Previous cardiovascular disease: myocardial infarction or stroke
Malignancy: especially malignancies that metastasise to the brain (e.g. lung cancer, breast cancer and malignant melanoma)
Risk factors for thromboembolic disease: increase the likelihood of a pulmonary embolus (e.g. history of thromboembolic disease, current malignancy, surgery within the last two months, immobility, lower limb trauma or fracture and being pregnant or up to six weeks postpartum).11
Conditions which may cause acute blood loss: menorrhagia, inflammatory bowel disease or peptic ulcer disease
Conditions which may cause autonomic failure: Parkinson’s disease or diabetes mellitus
Conditions which may cause metabolic abnormalities: diabetes mellitus and renal disease

Allergies
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs anaphylaxis).

Drug history
Ask if the patient is currently taking any prescribed medications or over-the-counter remedies:

“Are you currently taking any prescribed medications or over-the-counter treatments?”

If the patient is taking prescribed or over-the-counter medications, document the medication name, dose, frequency, form and route.
Ask the patient if they’re currently experiencing any side effects from their medication:

“Have you noticed any side effects from the medication you currently take?”

Medication examples
Medications commonly prescribed to patients with dizziness include:

Prochlorperazine (also known as Stemetil or Buccastem): for vertigo
Cinnarizine: for vertigo
Betahistine: for Ménière’s disease
Fludrocortisone: for orthostatic hypotension

Family history
Ask if there is any family history of cardiovascular disease or neurological disease:

“Do any of your parents or siblings have a history of heart disease, stroke or other problems with the nerves?” 

Social history
General social context
Explore the patient’s general social context including:

the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stair lift)
who else the patient lives with and their personal support network
what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)
if they have any carer input (e.g. twice daily carer visits)

Understanding the patient’s daily activities and social context allows you to consider the risk posed by further dizziness episodes.
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years‘ the patient has smoked for to determine their cardiovascular risk profile:

pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes

See our smoking cessation guide for more details.
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
See our alcohol history taking guide for more information
Excess alcohol use can be a cause of dizziness.
Recreational drug use
Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.
Recreational drugs can cause dizziness.
Fluid intake
Patients with poor fluid intake are at increased risk of pre-syncope secondary to reduced circulating volume.
Occupation
Ask about the patient’s current occupation:

Identify any high-risk activities (e.g. working at heights, operating heavy machinery).
If the patient is experiencing episodes of dizziness and works with heavy machinery or at heights, it is important to advise them to take time off work until they have been fully investigated.

Driving
If the patient drives and has presented with dizziness, it is important to advise them not to drive until they have been fully investigated and to inform the relevant driving authority (e.g. Driver and Vehicle Licensing Agency) of their current medical issues.

Closing the consultation
Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

Reviewer
Dr Paul Molyneux
Consultant Neurologist
West Suffolk Hospital Foundation Trust and Addenbrooke’s Hospital

References

Agarwal, K et al. Acute vertigo: getting the diagnosis right. BMJ 2022;378:e069850
Seemungal, BM & Bronstein, AM. A practical approach to acute vertigo. Practical Neurology 2008;8:211-221.
Assessment of Dizziness. From: BMJ Best Practice. Available from: [LINK]
Stanton, M, Freeman, AM. Vertigo. [Updated 2022 Mar 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: [LINK]. 
Seemungal, BM & Bronstein, AM. A practical approach to acute vertigo. Practical Neurology 2008;8:211-221.
Seemungal, BM & Bronstein, AM. A practical approach to acute vertigo. Practical Neurology 2008;8:211-221.
Popkirov, S, Staab, JP, Stone, J.  Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Practical Neurology 2018; 18:5-13.
BMJ Best Practice. Assessment of Dizziness. Available from: [LINK]
Silverston, P. SAFER diagnosis: a teaching system to help reduce diagnostic errors in primary care. British Journal of General Practice 2020 70(696):354-355
Agarwal, K et al. Acute vertigo: getting the diagnosis right. BMJ 2022;378:e069850
NICE CKS. Pulmonary embolism. Available from: [LINK]