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Assessment and treatment of dizziness
  1. Institute of Clinical Neurosciences, Royal Prince Alfred Hospital and the University of Sydney, Sydney, Australia
  1. Professor G M Halmagyi, Department of Neurology, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Sydney, Australia emailmichael{at}

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“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 W B Matthews. Practical Neurology. Oxford, Blackwell, 1963.

These words are not quite as true today as when Bryan Matthews wrote them nearly 40 years ago. There is now cause for cautious optimism. Recent clinical and scientific developments in the study of the vestibular system have made the clinician's task a little easier. We now know more about the diagnosis and even the treatment of conditions such as benign paroxysmal positioning vertigo, Menière's disease, acute vestibular neuritis, migrainous vertigo, and bilateral vestibulopathy than we did in 1963 and our purpose here is to introduce the clinician to facts worth knowing.

(A) The patient who has repeated attacks of vertigo, but is seen while well


”Doctor I get dizzy”. This is of course one of the most common problems encountered in office practice and the one to which Matthews was alluding. The clinician's first job is to sort out whether the dizzy patient is having attacks of vertigo, or attacks of some other paroxysmal symptom. So what is vertigo and what are its mechanisms and clinical characteristics ?

The first point about vertigo is that it is an illusion of rotation and that it is always due to asymmetry of neural activity between the left and right vestibular nuclei. This is true whether the vertigo is induced by being spun around and then suddenly stopped, whether it is induced by having cold water squirted in one ear, whether it is induced by otoconial particles rumbling up and down a semicircular canal duct, or whether …

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