Aproch to vertigo,type of vertigo, pathophysiology, diagnosis , differential, management
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Vertigo is a broad clinical topic. The main areas are:
- Definition and symptom classification
- Peripheral versus central vertigo and mechanisms
- Focused history and bedside examination
- Diagnostic approach and key tests
- Differential diagnosis
- Acute and cause-specific management
- Red flags requiring urgent stroke assessment
The core clinical principle is to first distinguish true vertigo, an illusion of movement, from presyncope, imbalance, and nonspecific dizziness. Then classify the syndrome by timing and triggers, and specifically exclude a central cause such as posterior-circulation stroke in patients with continuous acute vertigo or neurologic features.
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Vertigo is a broad clinical topic. The main areas are:
- Definition and symptom classification
- Peripheral versus central vertigo and mechanisms
- Focused history and bedside examination
- Diagnostic approach and key tests
- Differential diagnosis
- Acute and cause-specific management
- Red flags requiring urgent stroke assessment
The core clinical principle is to first distinguish true vertigo, an illusion of movement, from presyncope, imbalance, and nonspecific dizziness. Then classify the syndrome by timing and triggers, and specifically exclude a central cause such as posterior-circulation stroke in patients with continuous acute vertigo or neurologic features.
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"Vertigo"[MeSH Terms] AND "Diagnosis, Differential"[MeSH Terms]
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2023 guideline acute dizziness vertigo bedside diagnosis HINTS GRACE-3 Society for Academic Emergency Medicine
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https://pubmed.ncbi.nlm.nih.gov/37166022/
Vertigo: Approach, Types, Pathophysiology, Diagnosis, Differential Diagnosis and Management
Definition
Vertigo is a false sensation of movement, usually spinning, either of the patient or of the surroundings. It results from asymmetric activity in the vestibular system. It must be distinguished from:
- Presyncope: feeling of impending faint
- Disequilibrium: imbalance while walking
- Nonspecific dizziness: vague light-headed or floating sensation
Bradley and Daroff's Neurology in Clinical Practice, p. 281.
1. Types of vertigo
A. Peripheral vertigo
Due to disease of the labyrinth, vestibular nerve, or vestibular ganglion.
Features
- Severe spinning sensation
- Nausea, vomiting, sweating
- Hearing loss, tinnitus, or ear fullness may occur
- Horizontal-torsional, unidirectional nystagmus that is suppressed by visual fixation
- No focal neurological deficit
- Patient can usually walk with assistance
Causes
- Benign paroxysmal positional vertigo (BPPV)
- Vestibular neuritis
- Labyrinthitis
- Ménière disease
- Ototoxic drugs
- Perilymph fistula
- Vestibular schwannoma
B. Central vertigo
Due to lesions in the brainstem, cerebellum, or central vestibular pathways.
Features
- Often less intense spinning but marked gait ataxia
- Vertical, direction-changing, or pure torsional nystagmus
- Nystagmus is not suppressed by fixation
- Diplopia, dysarthria, dysphagia, weakness, numbness, severe headache, or incoordination may occur
- May be due to posterior circulation stroke
Causes
- Cerebellar or brainstem stroke
- Vertebrobasilar transient ischemic attack
- Multiple sclerosis
- Vestibular migraine
- Posterior fossa tumor
- Chiari malformation
2. Pathophysiology
Balance depends on integration of:
- Vestibular input from semicircular canals and otolith organs
- Visual input
- Proprioceptive input from muscles and joints
- Processing by the brainstem, cerebellum, and cerebral cortex
At rest, both vestibular nerves have equal tonic firing. A unilateral peripheral lesion reduces activity from one labyrinth. The brain interprets this imbalance as continuous head rotation toward the healthy side, causing:
- Vertigo
- Nystagmus
- Nausea and vomiting
- Postural instability
BPPV: displaced calcium carbonate crystals, otoconia, enter a semicircular canal, usually the posterior canal. Positional movement causes abnormal endolymph flow and short episodes of vertigo.
Ménière disease: endolymphatic hydrops causes episodic dysfunction of cochlear and vestibular structures.
Vestibular neuritis: usually post-viral inflammation of the vestibular nerve causes acute unilateral vestibular hypofunction.
3. Clinical approach to a patient with vertigo
A. History
Ask about:
| Point | Diagnostic importance |
|---|---|
| Onset | Sudden onset may be BPPV, vestibular neuritis, or stroke |
| Duration | Seconds, minutes, hours, or continuous for days |
| Trigger | Positional trigger suggests BPPV |
| Hearing symptoms | Hearing loss/tinnitus suggests inner-ear disease |
| Neurological symptoms | Suggest central lesion or stroke |
| Headache/migraine | Suggests vestibular migraine or hemorrhage |
| Recent viral illness | Suggests vestibular neuritis/labyrinthitis |
| Drugs | Aminoglycosides, anticonvulsants, sedatives, alcohol, antihypertensives |
| Vascular risks | Hypertension, diabetes, smoking, atrial fibrillation, prior stroke |
A useful modern classification is based on timing and triggers:
- Triggered episodic vestibular syndrome: brief positional attacks, commonly BPPV
- Spontaneous episodic vestibular syndrome: attacks without positional trigger, e.g., Ménière disease, vestibular migraine, TIA
- Acute vestibular syndrome: acute persistent vertigo lasting days, e.g., vestibular neuritis or posterior circulation stroke
B. Examination
- Vital signs, including postural blood pressure
- Ear examination and hearing assessment
- Full neurologic examination
- Gait and truncal stability
- Eye movements and nystagmus
- Cerebellar signs: finger-nose test, heel-shin test, dysarthria
Positional tests
Dix-Hallpike test
- Used for suspected posterior-canal BPPV.
- Positive if it causes transient vertigo and characteristic torsional-upbeating nystagmus.
HINTS examination
Used only in continuous acute vestibular syndrome with spontaneous nystagmus, and only by clinicians trained in it.
- Head impulse: abnormal corrective saccade suggests peripheral disease
- Nystagmus: direction-changing nystagmus suggests central disease
- Test of Skew: vertical ocular misalignment suggests central disease
A normal head impulse, direction-changing nystagmus, or skew deviation is concerning for stroke. Current GRACE-3 guidance recommends HINTS only in trained hands and MRI confirmation for central or equivocal findings. GRACE-3 guideline
4. Differential diagnosis
| Disorder | Typical pattern |
|---|---|
| BPPV | Brief episodes, seconds to less than 1 minute, triggered by turning in bed or looking up; no hearing loss |
| Vestibular neuritis | Acute severe continuous vertigo lasting days; no hearing loss; often post-viral |
| Labyrinthitis | Acute continuous vertigo plus hearing loss and tinnitus |
| Ménière disease | Recurrent attacks lasting 20 minutes to hours, fluctuating sensorineural hearing loss, tinnitus, aural fullness |
| Vestibular migraine | Recurrent vertigo with current/past migraine, photophobia, phonophobia or migraine headache |
| Posterior circulation stroke | Acute persistent vertigo with severe ataxia, neurological signs, central nystagmus or high vascular risk |
| TIA | Brief spontaneous episodes with vascular risk factors, sometimes brainstem symptoms |
| Acoustic neuroma | Gradual unilateral sensorineural hearing loss, tinnitus, imbalance |
| Drug/alcohol toxicity | Dizziness or imbalance after relevant exposure |
| Orthostatic hypotension/arrhythmia | Presyncope rather than true spinning vertigo |
| Anxiety/PPPD | Persistent non-spinning dizziness, often exacerbated by upright posture or visually complex environments |
5. Investigations
Investigations are guided by clinical findings.
- Audiometry: hearing loss, Ménière disease, vestibular schwannoma
- ECG and glucose: if presyncope, arrhythmia, or metabolic cause is possible
- Complete blood count, electrolytes, thyroid function: only if indicated clinically
- MRI brain with diffusion-weighted imaging: suspected posterior circulation stroke, central signs, atypical course, or equivocal bedside examination
- CT brain: has poor sensitivity for posterior fossa stroke and should not be used routinely to exclude it in isolated acute vertigo
- MRI internal auditory canals: unilateral progressive sensorineural hearing loss or suspected vestibular schwannoma
6. Management
General measures
- Reassure and maintain hydration.
- Treat vomiting with short-term antiemetics, e.g., ondansetron, prochlorperazine, or promethazine.
- Short-term vestibular suppressants may be used for severe acute symptoms, e.g., antihistamines such as meclizine or a brief course of benzodiazepine.
- Avoid vestibular suppressants beyond 2-3 days in vestibular neuritis because they can delay central compensation.
- Advise fall precautions and avoid driving during active attacks.
Cause-specific management
1. BPPV
- Canalith repositioning maneuver, usually the Epley maneuver, is first line.
- Brandt-Daroff exercises may be used for recurrent symptoms.
- Drugs are not definitive treatment.
2. Vestibular neuritis
- Short course of antiemetic or vestibular suppressant for severe symptoms only.
- Consider early corticosteroids in selected patients.
- Begin vestibular rehabilitation exercises early after the acute phase.
3. Labyrinthitis
- Supportive treatment for viral cases.
- Urgent ENT assessment if bacterial otitis media, meningitis, severe hearing loss, or suspected bacterial labyrinthitis.
- Treat the underlying infection if present.
4. Ménière disease
- Reduce salt intake and avoid individual triggers such as alcohol, caffeine, and nicotine.
- Diuretics may be used in selected patients.
- ENT referral for recurrent attacks, intratympanic therapy, or surgical options.
- Hearing rehabilitation where required.
5. Vestibular migraine
- Identify and avoid triggers.
- Regular sleep, hydration, exercise, and migraine lifestyle measures.
- Acute migraine treatment and preventive therapy in frequent attacks.
6. Central vertigo or suspected stroke
- This is an emergency.
- Activate acute stroke pathway.
- Urgent MRI/vascular imaging as clinically appropriate.
- Manage thrombolysis or thrombectomy eligibility according to time of onset and imaging findings.
7. Red flags requiring urgent referral
Urgent emergency evaluation is needed with:
- New focal neurological deficit
- Severe inability to stand or walk independently
- New severe headache or neck pain
- Vertical or direction-changing nystagmus
- Diplopia, dysarthria, dysphagia, facial weakness, or limb weakness
- New unilateral hearing loss with acute vestibular syndrome
- High vascular risk or known vertebrobasilar disease
- Continuous vertigo with atypical features or no clear peripheral diagnosis
Conclusion
The key to vertigo is distinguishing peripheral from central causes. BPPV is common and is diagnosed by Dix-Hallpike testing and treated with Epley maneuver. Continuous acute vertigo requires careful neurologic, gait, eye movement, and nystagmus assessment to avoid missing posterior circulation stroke.
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