Dizziness is a description, not a diagnosis. Minor trauma can disturb balance through several mechanisms, some readily treatable and others more difficult to define. The medico-legal expert must establish what the claimant means by dizziness, identify the likely cause and explain whether the accident materially contributed to it.
The symptom must first be described properly.
Claimants use “dizziness” to describe very different experiences.
Some report rotational vertigo, as though they or the room are spinning. Others describe light-headedness, faintness, rocking, visual disorientation or unsteadiness while walking. A claimant may feel secure when sitting but unstable in crowds, on patterned floors or when turning their head.
These distinctions matter because they point towards different causes.
NICE defines dizziness broadly to include spinning, vague unsteadiness, light-headedness and presyncope. Its guidance distinguishes sudden neurological presentations, positional vertigo, postural hypotension and vestibular migraine rather than treating dizziness as a single condition.
The expert should ask when symptoms began, how long individual episodes last and what provokes them. Turning in bed, standing quickly, walking in darkness, moving through a supermarket or travelling in a car may each suggest a different pattern.
Associated symptoms also require attention. These include headache, nausea, hearing loss, tinnitus, double vision, weakness, altered sensation, neck pain, palpitations and loss of consciousness.
A report stating only that the claimant “has suffered dizziness since the accident” has not completed the clinical analysis.
Acute warning signs come first.
Dizziness following trauma is often benign, but new balance disturbance can form part of a more serious neurological presentation.
NICE advises immediate assessment where sudden dizziness is accompanied by focal neurological abnormalities, new deafness or new unsteadiness and is not explained by benign positional vertigo or postural hypotension. Following a head injury, loss of balance, abnormal walking, nystagmus and other focal neurological problems may influence the need for urgent investigation.
The medico-legal examination may take place long after the acute period, but the expert should still establish what happened initially. Was the claimant confused, vomiting or unable to walk? Was there loss of consciousness or amnesia? Were neurological examinations normal? Was imaging performed, and why?
New or progressive symptoms should not be attributed retrospectively to an old minor injury without appropriate clinical assessment. A claimant who now has worsening imbalance, new hearing loss or focal neurological signs may require current medical investigation before a final causation opinion is offered.
Positional vertigo is easily missed.
Benign paroxysmal positional vertigo, or BPPV (Benign Paroxysmal Positional Vertigo), should be considered where brief rotational vertigo is triggered by head movement, such as rolling in bed, looking upwards or bending down.
NICE specifically notes that BPPV is common after head injury. It recommends the Hallpike manoeuvre where transient rotational vertigo occurs with head movement, and a trained clinician is available. Where BPPV is confirmed, a canalith repositioning procedure, such as the Epley manoeuvre, should be offered by someone trained to perform it, provided there is no unstable cervical spine disease.
This is important medico-legally because untreated BPPV may be mistaken for persistent concussion. It may also respond to a brief and specific intervention rather than requiring open-ended neurological rehabilitation.
Post-traumatic BPPV may involve more than one semicircular canal and may require repeated repositioning procedures. A systematic review nevertheless found that the available evidence did not establish worse overall resolution rates than in non-traumatic BPPV, while acknowledging weaknesses in the underlying studies.
An expert should not diagnose BPPV from the history alone where formal positional testing has not been carried out.
Concussion is possible, but not automatic.
Dizziness and balance difficulty may occur after concussion or mild traumatic brain injury. A claimant may also report headache, poor concentration, visual sensitivity, fatigue and intolerance of busy environments.
The absence of a skull fracture or abnormal routine scan does not, by itself, determine whether concussion occurred. The opinion should be based on the accident mechanism and evidence of acute altered consciousness, confusion, memory disturbance or other compatible symptoms.
At the same time, dizziness after an accident should not automatically be labelled post-concussion syndrome. Post-traumatic dizziness may have peripheral vestibular, central vestibular and non-vestibular causes, and more than one mechanism may operate in the same patient.
Pre-existing migraine, ear disease, medication effects, anxiety, postural blood-pressure changes and visual problems may provide competing or contributing explanations. NICE also advises considering vestibular migraine where episodes last between five minutes and 72 hours in a person with a history of recurrent headache.
The diagnosis should follow the evidence rather than act as a general label for every symptom appearing after a minor collision.
Neck pain does not prove cervical dizziness.
Some claimants report that dizziness began with a whiplash-type neck injury and is provoked by neck movement. A cervical contribution may be considered, particularly where dizziness and neck symptoms follow a closely related course.
There are no universally accepted diagnostic criteria for cervicogenic dizziness, and the diagnosis commonly depends on excluding vestibular, neurological and cardiovascular explanations. A systematic review found that research and clinical assessment remain limited by the lack of accepted criteria.
The expert should therefore avoid concluding that dizziness arises from the cervical spine merely because neck pain is also present. Head movement can provoke BPPV, while discomfort and guarded movement may affect balance without proving a specific cervical vestibular disorder.
A reasoned opinion should state what alternatives were investigated and why a cervical explanation is considered more or less likely.
Persistent symptoms may change character.
A short-lived vestibular event can sometimes develop into a more persistent pattern of unsteadiness and visual sensitivity.
Persistent postural-perceptual dizziness is characterised by dizziness, non-spinning vertigo or unsteadiness on most days for at least three months. Symptoms are typically aggravated by upright posture, movement and complex or moving visual surroundings. It may follow a vestibular disorder, another medical event or psychological distress and can coexist with other diagnoses.
This is a recognised functional vestibular disorder. It should not be diagnosed simply because tests are normal or because anxiety is present.
The history must meet the positive clinical pattern. The expert should identify the triggering condition, symptom persistence and environmental provocations rather than using a functional diagnosis as a default explanation for unexplained dizziness.
The evidence should extend beyond the claimant’s account.
The claimant’s account remains important, but the expert should look for supporting chronology and functional evidence.
Emergency, GP, physiotherapy, ENT, audiology and neurology records may show when dizziness was first reported and whether the description remained consistent. Earlier records may identify previous vertigo, migraine, falls, hearing problems or medication likely to affect balance.
Examination should include gait and balance where appropriate, eye movements, neurological findings and positional testing within the expert’s competence. NICE rehabilitation guidance advises asking about new and pre-existing dizziness or vestibular symptoms after traumatic injury and considering assessment for BPPV and head injury.
The functional effect should be explored specifically. Has the claimant fallen? Can they use stairs, shop independently, work at height or drive? Are activities avoided because dizziness occurs, or because the claimant fears that it might?
Treatment should follow the cause.
There is no standard treatment package for post-traumatic dizziness.
BPPV may require repositioning manoeuvres. Migraine-related symptoms require an appropriate migraine assessment. Postural hypotension, medication effects and hearing disorders need their own management. Persistent concussion-related vestibular difficulty may justify specialist vestibular rehabilitation.
A systematic review and meta-analysis found evidence that vestibular rehabilitation can reduce perceived dizziness following mild traumatic brain injury, although the number and quality of available studies limit certainty about the size and duration of benefit.
The expert should therefore identify the proposed treatment’s purpose rather than recommending generic physiotherapy. Where the diagnosis remains uncertain, specialist neuro-otological, vestibular or neurological assessment may be needed before prognosis is finalised.
Dizziness after minor trauma may be genuine, disabling and treatable even where routine investigations are normal. It may also arise from a condition unrelated to the accident or from several interacting causes.
The expert’s responsibility is not to decide whether the symptom sounds disproportionate. It is to define the presentation, test the possible mechanisms and state how securely the evidence links the continuing balance problem to the accident.
