Edited by: Thomas Brandt, Ludwig-Maximilians-Universität München, Germany
Reviewed by: Dario A. Yacovino, Instituto de Investigaciones Neurológicas “Raúl Carrea” (FLENI), Argentina; Seong-Hae Jeong, Chungnam National University Hospital, South Korea; Carlos R. Gordon, Tel Aviv and Meir Medical Center, Israel; Arata Horii, Suita Municipal Hospital, Japan
*Correspondence: Alexandre Bisdorff, Department of Neurology, Centre Hospitalier Emile Mayrisch, 4005 Esch-sur-Alzette, Luxembourg. e-mail:
This article was submitted to Frontiers in Neuro-otology, a specialty of Frontiers in Neurology.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in other forums, provided the original authors and source are credited and subject to any copyright notices concerning any third-party graphics etc.
Vertigo, dizziness, and unsteadiness (VDU) are common symptoms traditionally considered to result from different kinds of vestibular and non-vestibular dysfunctions. The epidemiology of each symptom and how they relate to each other and to migraine, agoraphobia, motion sickness susceptibility (MSS), vaso-vagal episodes (VVE), and
Vertigo and dizziness rank among the most common reasons for consultation and referral to specialist care (Sloane,
An approach to the patient based on the quality of four mutually exclusive symptoms which would predict the underlying cause has been propagated since the 1970s (Drachman and Hart,
The international vestibular community has started to classify vestibular disorders. A first step was to propose definitions of symptoms, which are distinctive, non-overlapping and not mutually exclusive entities, and without any hypothesis regarding etiology or mechanism (Bisdorff et al.,
The vestibular system works at a subconscious level and serves many purposes related to oculo-motor control, balance regulation, and perception of self-motion (Massion and Woollacott,
Vertigo and dizziness are also frequently associated with other common diseases and conditions, such as migraine (Neuhauser et al.,
This study sets out to examine the prevalence of vertigo, dizziness, and unsteadiness (VDU) in an adult population. To avoid the problem of the uneven use of terms, it uses purely phenomenological definitions for each. It also makes it possible to establish the co-occurrence of the three symptoms and whether they relate differently to markers of severity for balance disorders like falls and to certain co-morbidities of vestibular disorders.
In the
The study used a self-administered questionnaire, which included some basic demographic data and a medical part. The questions on VDU were taken from the vestibular part of the Vertigo Symptom Scale (VSS) (Yardley et al., “a feeling that things are spinning or moving around”: vertigo, “a feeling of being light-headed, ‘swimmy’ or giddy”: dizziness, “feeling unsteady, about to lose balance”: unsteadiness.
For each item participants ticked the duration and frequency of episodes over the last year. Two items refer to severity: balance-related falls and “incapacity to stand or walk without support” ( = severe unsteadiness). The developer of the VSS defined two composite scores:
vertigo short for VDU symptoms lasting for up to 1 h (VDUshort), vertigo acute for VDU of >1 h plus severe unsteadiness, falls, and nausea (VDUacute).
For the composite scores a ≥4 cut-off was chosen so as to have a significant level of symptoms.
Further inclusions were the migraine identifier (Lipton et al.,
To correct for differences between the sample and the general population of Lorraine, weights were defined for gender, age, and level of education. In each category the weights were the ratio of the proportion in the general population to the observed proportion in the sample. All statistical analyses and tests were performed with weighted data. The statistical package used was SPSS 16.0 for windows.
Bivariate associations were tested by applying Chi-squared tests. Multivariate logistic regression was used, with forward stepping, to explain binary variables from several quantitative and qualitative covariates. Odds-ratios (OR) estimates were derived from these logistic models.
Of the 3035 questionnaires returned 2987 (1471 women) were included, after rejecting those with too many missing or unusable data. The average age (
At least one VDU symptom had occurred at least once in the last 12 months in 59.2% of participants, vertigo (48.3%) was followed by unsteadiness (39.1%) and dizziness (35.6%). About 90% of each symptom episodes were of short (≤2 min) duration and occurred less than once per month (Table
Frequency | <2 min | 2–20 min | 20 min–1 h | Hours | >12 h | |
---|---|---|---|---|---|---|
1–3/year | Vertigo | 25.98* | 3.26* | 1.52 | 1.58 | 1.17 |
Dizziness | 19.44 | 2.59 | 1.25 | 1.29 | 0.97 | |
Unsteadiness | 22.71 | 2.20 | 1.35 | 1.19 | 1.03 | |
4–12/year | Vertigo | 14.21* | 0.92 | 0.66 | 0.61 | 0.14 |
Dizziness | 10.18 | 1.32 | 0.44 | 0.23 | 0.22 | |
Unsteadiness | 9.89 | 1.19 | 0.53 | 0.4 | 0.21 | |
>1/month | Vertigo | 4.42* | 0.67 | 0.31 | 0.12 | 0.09 |
Dizziness | 2.41 | 0.77 | 0.25 | 0.14 | 0.08 | |
Unsteadiness | 2.94 | 0.61 | 0.29 | 0.20 | 0.15 | |
>1/week | Vertigo | 1.71 | 0.18 | 0.10 | 0.14 | 0.06 |
Dizziness | 1.03 | 0.24 | 0.13 | 0.11 | 0.00 | |
Unsteadiness | 1.28 | 0.25 | 0.10 | 0.04 | 0.05 |
Most participants (69.4%) with symptoms experienced more than one type in various combinations (Table
Fallers (%/Group) | Severe unsteadiness (%/Group) | Nausea | ||||
---|---|---|---|---|---|---|
No sympt | 49.6 | 31.7 | 40.8 | 1.2 | 1.1 | 20.5 |
Vert only | 9 | 11.8 | 10.4 | 2.0 | 2.9* | 45.3* |
Dizz only | 3.5 | 2.6 | 3.1 | 0.9 | 1.1 | 46.0* |
Vert + dizz | 5.6 | 7.6 | 6.6 | 3.7 | 4.7* | 51.3* |
Unstead only | 4.6 | 4.7 | 4.6 | 4.4 | 5.7* | 48.0* |
Unstead + vert | 8 | 9.3 | 8.6 | 11.4* | 11.9* | 52.1* |
Unstead + dizz | 3.6 | 2.8 | 3.2 | 14.1* | 17.3* | 65.5* |
Vert + dizz + unstead | 16.1 | 29.6 | 22.7 | 16.4* | 22.3* | 68.1* |
The risk for falls and severe unsteadiness was significantly increased if symptoms came in combinations rather than in isolation, particularly if the combination included unsteadiness.
The risk of nausea was similarly increased for each VDU symptom – and still further in case of symptom combinations.
Balance-related falls and severe unsteadiness were about three times more frequent if the symptoms lasted >1 h rather than ≤1 h, and this was true for all three symptoms.
In women the symptoms were more frequent than in men in most age groups except for ≥70 years. The prevalence was similar across the various age groups except that in women VDUacute was lower for age group 40–49 years (Table
Age groups (years) | VDUshort |
VDUacute |
Fallers |
Severe unsteadiness |
||||
---|---|---|---|---|---|---|---|---|
M/F (%) | M/F (%) | M/F (%) | M/F (%) | |||||
19–29 | 21/31 | <0.01 | 4/12 | <0.01 | 5/11 | <0.05 | 5/13 | <0.02 |
30–39 | 12/33 | <0.01 | 4/12 | <0.01 | 6/8 | ns | 6/10 | <0.01 |
40–49 | 15/29 | <0.01 | 3/5 | ns | 4/7 | ns | 3/11 | <0.01 |
50–59 | 14/34 | <0.01 | 2/12 | <0.01 | 6/8 | ns | 6/12 | <0.01 |
60–69 | 14/21 | <0.01 | 4/8 | ns | 4/8 | <0.01 | 6/9 | ns |
≥70 | 17/17 | ns | 7/12 | ns | 3/8 | ns | 5/7 | ns |
Leaving aside contraception, 55.4% took no medication and 4.4% more than six drugs. The number of drugs increased with age. The prevalence of VDUshort and VDUacute increased significantly with the number of drugs, independently of age and gender (Table
Age groups |
||||||||||
---|---|---|---|---|---|---|---|---|---|---|
436 |
538 |
587 |
558 |
632 |
220 |
2971 |
||||
Number of drugs | 18–29 years (%) | 30–39 years (%) | 40–49 years (%) | 50–59 years % | 60–69 years % | ≥70 years % | Total % | VDUshort % (OR) | VDUacute % (OR) | Falls % (OR) |
0 | 85.6 | 74.3 | 72.1 | 46.8 | 25.8 | 11.8 | 55.4 | 18.5 (1) | 4 (1) | 5.1 (1) |
1 | 8.9 | 16.4 | 14.8 | 22.0 | 16.9 | 11.8 | 14.7 | 24.6 (1.58) | 9.5 (2.78) | 9.8 (2.2) |
2 | 3.4 | 4.3 | 5.3 | 18.1 | 13.1 | 26.4 | 10.3 | 23.8 (1.85) | 6.3 (2.13) | 5.3 (1.3) ns |
3 | 1.4 | 3.3 | 1.9 | 8.1 | 16.5 | 15.0 | 7.3 | 15.9 (1.18) ns | 5.6 (2.02) | 6.6 (1.7) ns |
4 | 0.2 | 1.1 | 1.9 | 5.7 | 11.1 | 8.2 | 4.6 | 28.1 (2.72) | 7.9 (3.43) | 3.6 (1.0) ns |
5 | 0 | 0.2 | 2.0 | 3.0 | 7.1 | 9.1 | 3.2 | 27.7 (2.74) | 15.6 (7.80) | 13.2 (4.1) |
≥6 | 0.5 | 0.4 | 1.9 | 3.2 | 9.5 | 17.7 | 4.4 | 40.2 (4.95) | 19.8 (9.35) | 12.3 (3.8) |
VDUshort (OR) | 1 | 0.77 ns | 0.68 | 0.65 | 0.33 | 0.27 | ||||
VDUacute (OR) | 1 | 0.84 ns | 0.35 | 0.45 | 0.26 | 0.38 |
The global prevalence of migraine was 17.90% with the typical female predominance and decrease over age 50 years, which is similar to European figures (Stovner and Andree,
The average agoraphobia score was 4.1 which is comparable with data from the literature (Mizes and Crawford,
Each VDU symptom was highly correlated with every co-morbidity in Chi-squared tests (
Vertigo | Dizziness | Unsteadiness | |
---|---|---|---|
Migraine | 1.11 (1.01–1.22) | 1.36 (1.21–1.52) | 1.14 (1.03–1.26) |
MSS | 1.18 (1.09–1.26) | ns | ns |
VVE | 1.31 (1.20–1.43) | 1.18 (1.08–1.29) | ns |
Agoraphobia | 1.32 (1.22–1.41) | ns | ns |
AD | 1.22 (1.16–1.34) | 1.23 (1.12–1.36) | ns |
Anxiety-depression and female gender significantly increased the risk for VDUshort, VDUacute, and all co-morbidities except AD for VVE. A separate multivariate regression analysis was therefore conducted in men and women with and without AD (Table
Migraine increased the risk for VDUshort in men and women and for VDUacute in women, independently of AD.
Vaso-vagal episodes increased the risk for VDUshort in men with and without AD, in women without AD, and for VDUacute in AD women.
In the global analysis the highest OR for MSS were found for female gender 2.53 (CI 1.92–3.34), followed by AD (OR 2.04; CI 1.51–2.76) and migraine (OR 1.48; CI 1.10–1.98). When controlling for AD and gender, migraine was not significant in men but still in non-AD women, MSS did not increase the risk for VDUshort or VDUacute.
In the global analysis the highest risks for agoraphobia were AD (OR 3.48; CI 2.63–4.61) and female gender OR 2.36 (CI 1.78–3.11). When the data were controlled for gender and AD, agoraphobia was found to increase the risk for VDUshort, VDUacute in non-AD women. In men the only factor was the combination of AD and MSS.
Vertigo, dizziness, and unsteadiness have a high and roughly even prevalence throughout adult life. The three symptoms are correlated with each other, usually appear in short episodes and in various combinations rather than in isolation (Tables
This challenges the traditional view that vertigo is a more specific symptom resulting from dysfunction of the inner ear or its immediate connections in the brain stem and cerebellum (Perrin et al.,
Occasional and short lasting and isolated symptoms are very common in the population of all ages and might not mean anything serious. On the other hand combinations of symptoms and those lasting for >1 h were correlated with markers of severity like falls.
Previous epidemiological studies found a similar symptom prevalence (Hannaford et al.,
This points to a big gap between the prevalence of VDU symptoms and that of vestibular diseases. Indeed, the sum of the 1-year prevalence of the most common vestibular disorders – benign paroxysmal positional vertigo 1.6% (von Brevern et al.,
Drugs might be an important factor (Table
A surprising finding is that when controlling for drug intake, VDU decreased with age.
This suggests that drugs or the diseases for which they are prescribed explain a part of VDU, particularly in the elderly and those elderly people who do not need to take any or only a few drugs are very healthy and fall less. On the other hand, in young adults who take little or no medication, the VDU prevalence is similar to older adults, who usually take many drugs. In young adults, factors like migraine and VVE seem to be more important for explaining VDU.
All co-morbidities examined in this study were correlated with each VDU symptom, which suggests they arise from common factors, but each symptom might also have a specific component. In logistic models controlling for each vestibular symptom, age and gender some differences appeared (Table
In this model agoraphobia was only correlated with vertigo and AD with vertigo and dizziness. One might have expected from the data from behavioral and emotional complications of vestibular disorders that dizziness would come out more prominently here rather than vertigo (Ruckenstein and Staab,
The co-morbidities examined in this study are known to be interconnected. Migraine has a link to MSS (Marcus et al.,
Migraine has a robust link to VDUshort in men and women independently of AD and other co-morbidities, in women also to VDUacute. This finding supports the importance of migraine for VDU.
Vaso-vagal episode has a link to VDUshort in non-AD-men and women when controlling for the other co-morbidities and suggest it to be an important factor for short lasting vestibular symptoms, particularly in the young and middle aged and is in line with a recent German study (Radtke et al.,
From the global results the main risk factors for MSS were AD and female gender. When controlling for these factors MSS was not linked to VDU and not to migraine in men and only weakly in women. Since migraine and anxiety are more common in women, this could explain why studies in migraine patients showed high rates of MSS (Marcus et al.,
In the global analysis the strongest explanatory factors for agoraphobia were AD and female gender. When controlling for gender and AD, VDU increased the risk of agoraphobia in women but not in men. In AD-men MSS increased the risk of agoraphobia. The interface of anxiety and vestibular disease is a complex topic (Balaban et al.,
The prevalence of VDU was found to be high across all age groups but tended to decrease in the age group >70. In other studies there was usually an increase with age, particularly in studies focusing on elderly populations of 65–90 year-olds (Jönsson et al.,
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The authors are grateful to Thierry Godefroy, MD (Medical Director) for logistical help and to the nurses of the Centre for Preventive Medicine for their contribution to participant recruitment; and to Nathalie Husson, M.Sc., for setting up the database, and to Alexis Lion, Ph.D., for data collection. This study was supported by unrestricted grants from Beaufour Ipsen Pharma, France, and Solvay Pharmaceuticals GmbH, Germany.