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History Taking for Giddiness

1. Define the Symptom First

Caution: patient descriptions can be unreliable and overlapping — timing and triggers are often more diagnostically useful than symptom type alone.

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2. Key History Questions

Onset & Timing

• When did it first start?
• Continuous or episodic?
• Duration of each episode (seconds / minutes–hours / days)?
• Frequency? Last episode?
• Do symptoms fully resolve between episodes?

Triggers

• Positional changes (rolling in bed → BPPV)?
• Standing up (orthostatic hypotension)?
• Head movements?
• Sound or pressure changes (perilymph fistula)?
• Salty food intake (Menière's disease)?
• Stress, exercise, excitement (familial ataxia)?
• Migraine triggers (light, stress)?

Mitigating / Exacerbating Factors

• What makes it better or worse?
• Does visual fixation suppress it?

Severity

• Does it limit daily activities or cause falls?

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3. Associated Symptoms

Ear (Labyrinthine) Symptoms

• Hearing loss (unilateral or bilateral, fluctuating?)
• Tinnitus (pulsatile or ringing?)
• Aural fullness
• Autophony
• Otorrhoea / otalgia
• Nausea, vomiting, sweating, diarrhea (autonomic features of true labyrinthine vertigo)

Neurological Symptoms (should NOT be present with pure labyrinthine vertigo — their presence points to a central cause)

• Extremity weakness or numbness
• Cranial nerve deficits (diplopia, facial weakness, dysphagia)
• Headache / visual aura / photophobia / phonophobia
• Memory loss or personality change
• Ataxia

Cardiovascular

• Palpitations (arrhythmia)
• Chest pain
• Syncope

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4. Medication History

• Current medications (aminoglycosides, loop diuretics, antihypertensives, antiepileptics — all ototoxic or vestibulotoxic)
• Polypharmacy in the elderly is a major cause of chronic dizziness

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5. Past Medical & Surgical History

• Prior ear infections, ear surgery, head trauma
• Hypertension, diabetes, cardiovascular disease
• Autoimmune disease (relevant for immune-mediated labyrinthitis)
• Migraines

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6. Family History

• Hereditary hearing loss or vestibular disorders
• Familial ataxia syndromes

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7. Social History

• Noise exposure (occupational or recreational)
• Tobacco and alcohol use
• Caffeine/stimulant intake (can exacerbate tinnitus and dizziness)

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8. Differential Diagnosis by Duration — Key Pointer

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9. Summary Table for History Taking in Vertigo

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History Taking for Seizures

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1. Obtain History from Both Patient AND Witness

• Interview patient and witness separately where possible to assess consistency
• Witness's recollection may be distorted by panic — try to get more than one witness
• Ask family if they have captured events on home video — invaluable
• Construct the event in temporal order: Prodrome → Aura → Ictus (ictal phase) → Postictal

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2. The Event Itself — Phase by Phase

Prodrome (hours to days before)

• Mood change, irritability, headache, sleep disturbance?
• Not part of the seizure itself but may warn of an impending event

Aura (seconds before — focal onset marker)

• Any warning the patient noticed just before losing awareness?
• Type of aura localises the epileptogenic zone:

Ictal Phase (the seizure itself — from witness)

• How did it begin? (focal jerking, eye deviation, head turn, automatisms?)
• Consciousness — fully aware, partially aware, or lost?
• Motor features: tonic (stiffening), clonic (rhythmic jerking), tonic-clonic, atonic (drop)?
• Automatisms: lip smacking, chewing, fumbling, picking, wandering?
• Eye deviation or head turn (lateralising — often contralateral to focus)
• Vocalisations or cry at onset (tonic-clonic)?
• Tongue biting (lateral biting = tonic-clonic seizure; tip biting = non-epileptic)
• Urinary or fecal incontinence?
• Colour: cyanosed, flushed, pale?
• Duration of the event?

Postictal Phase

• Confusion, drowsiness, amnesia?
• Duration of postictal confusion (longer = more severe seizure)
• Headache?
• Muscle soreness / aching?
• Todd's paralysis (focal weakness after focal motor seizure)?
• Able to recall the event? (Absent in GTC; present in focal aware seizures)

Absence seizures are a notable exception — no postictal phase

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3. Seizure Frequency and Pattern

• First-ever seizure or recurrent?
• Age at first seizure
• Total number of seizures / frequency
• Clustering? (multiple in 24 hours)
• Any change in seizure type or frequency recently?
• Longest seizure-free interval?
• Status epilepticus ever?

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4. Precipitating Factors / Triggers

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5. Past Medical History

• Perinatal/birth history: hypoxia, prematurity, neonatal seizures
• Developmental milestones: regression or delays suggest underlying syndrome
• Febrile seizures in childhood (associated with mesial temporal lobe epilepsy)
• CNS infections: meningitis, encephalitis, brain abscess
• Head trauma: loss of consciousness, depressed skull fracture, intracranial pathology
• Stroke or cerebrovascular disease (especially in elderly-onset epilepsy)
• Brain tumours or neurosurgery
• Neurocutaneous disorders: tuberous sclerosis, neurofibromatosis, Sturge-Weber
• Metabolic disorders: hypoglycaemia, hyponatraemia, renal/hepatic failure
• Psychiatric history: anxiety, depression (non-epileptic attack disorder common)

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6. Drug and Medication History

• Current antiseizure medications (ASMs) and compliance
• Recent dose changes or new prescriptions
• Drugs that lower seizure threshold: tramadol, bupropion, clozapine, ciprofloxacin, theophylline, isoniazid
• Drug-drug interactions with ASMs
• Recreational drugs, alcohol (especially withdrawal)
• Women of reproductive age: pregnancy (affects ASM clearance), oral contraceptive interaction with enzyme-inducing ASMs

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7. Family History

• Afebrile seizures in first- or second-degree relatives
• Febrile seizures
• Other paroxysmal disorders (migraine, syncope)
• Ask a senior female relative for best family history recall
• Genetic epilepsy syndromes (Dravet, GEFS+, juvenile myoclonic epilepsy)

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8. Social History

• Driving (legal obligation to report seizures in most jurisdictions)
• Occupation (working at heights, with machinery, near water — safety risk)
• Alcohol and substance use
• Sleep habits
• Psychosocial stressors

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9. Seizure Classification (ILAE 2017) — guides history taking

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10. Differential Diagnosis — Key Distinguishing Questions

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Summary Checklist