creation date: 2025-07-23 22:28
tags: Workups
Vertigo
Background
Vertigo is a symptom of illusionary movement. It is a type of dizziness which is differentiated from:
- Presyncope
- Disequilibrium
- Nonspecific lightheadedness
Vertigo can be perceived in several ways and arise from a number of central and peripheral causes.
Pathophysiology
The perception of motion involves the vestibular labyrinths which signal through the vestibular portion of CN8 to the brainstem vestibular nuclei. From the brainstem, the signals are relayed to the cerebellum, ocular motor nuclei (for coordinated eye motion during head motion), and spinal cord (to maintain upright posture).
The semicircular canals and otolith organs of the vestibular systems sense angular (spinning) and linear motion (floating/tilting), respectively. As a vestibular labyrinth is present on each side of the body, a difference in signalling through CN8 from both systems is recognized as motion. In cases of unilateral peripheral vestibular disorder, the left-right differences is incorrectly interpreted as motion or vertigo.
The central nervous system (brainstem level), which processes visual motion similarly to self-motion physiologically, results in a nonuniform description (Eg. self-motion vs. environment motion) of vertigo by different patients.
Differential Diagnosis
Vertigo is most commonly organized into peripheral and central disorders.
Peripheral causes account for ~80% of cases with BPPV, vestibular neuritis, and Meniere disease being most common.
Peripheral causes
The most common causes are:
- Benign Paroxysmal Positional Vertigo
- Vestibular neuritis
- Meniere disease (fullness of endolymph)
- Otosclerosis
Other less common causes include:
- Herpes zoster oticus (Ramsay Hunt syndrome)
- Labyrinthine concussion
- Perilymphatic fistula
- Semicircular canal dehiscence syndrome
- Cogan syndrome
- Recurrent vestibulopathy
- Acoustic neuroma
- Aminoglycoside toxicity
- Otitis media
Central causes
- Vestibular migraine
- Brainstem ischemia
- Cerebellar infarction and hemorrhage
- Chiari malformation
- Multiple sclerosis
- Episodic ataxia type 2
Initial Evaluation
History
In all cases of suspected vertigo or broader complaint of “dizziness”, it is important to verify the complaint is of vertigo and not another form of dizziness (eg. presyncope, dysequilibirium, psychogenic)
Questions to approach with include:
- Does you feel like you or the room were spinning or did you feel like you were fainting?
Features that point towards vertigo include:
- Perception of spinning sensation (sensitive but not specific)
- Time course no more than a few weeks (CNS adapts so it should subside)
- Acute prolonged severe vertigo (eg. vestibular neuronitis, stroke)
- Recurrent spontaneous attacks (eg. Meniere disease, vestibular migraine)
- Recurrent positionally triggered attacks (eg BPPV)
- Chronic persistent dizziness (eg. psychogenic, cerebellar ataxia; points to non vestibular etiology)
- Provoking factors: positional vertigo (standing up but also lying down, rolling over, etc.) and postural presyncope (standing only) are frequently confused
Signs and symptoms that are commonly associated with vertigo include:
- Nystagmus
- Postural instability
- Hearing loss
- Brainstem signs
Further history should allow for determination of etiology of the vertigo.
- Time course as above
- Clinical settings
- Predictive head movements or positions prior to symptom (BPPV)
- Viral syndrome preceding or accompanying (vestibular neuritis)
- History of migraine (vestibular migraine)
- Older patient, vascular risk factors, and/or cervical trauma (vertebrobasilar TIA, brainstem infarction)
- Older patient, vascular risk factors like hypertension (cerebellar infarction or hemorrhage)
- Aural fullness (Meniere disease)
- Auditory symptoms
Physical Exam
Examination should confirm vestibular dysfunction and distinguish between central and peripheral causes.
Signs and Symptoms
Nystagmus
Eyes slowly drift away from the target in one direction followed by a fast corrective “beat” in the reverse direction
Peripheral:
- Unidirectional, fast component towards normal side
- Always the same direction
- Horizontal with torsional component (never purely torsional or vertical)
- Suppressed with visual fixation (nystagmus increases with Frenzel lenses)
Central: - Can reverse in direction when patient looks towards slow component
- Can be in any direction
- Purely torsional or vertical nystagmus is a central sign
- Visual fixation does not suppress
Postural instability
- Unilateral peripheral disorders cause patients to lean or fall towards side of lesion
- Cerebellar stroke cause patients to be unable to walk without falling
Deafness or tinnitus
- Unilateral sensorineural hearing loss suggests a peripheral lesion
- Usually absent with central vertigo
Neurologic signs and symptoms
- Absent with peripheral vertigo
- Often present with central
Tests
A number of tests are used to confirm their respective etiologies such as the Dix-Hallpike maneuver (BPPV). Audiometry may be indicated if there are suspicions of hearing loss.
Importantly, the HINTS examination is used to rule in central vertigo. The exam is performed as follows:
- Head impulse test: while patient sitting and looking at examiner’s nose, thrust the head 20 degrees laterally then rapidly back to midline
- Note: oscillating between fast and slow movement keeps patient unaware. Only the rapid movement findings are relevant
- Nystagmus: while patient sitting, have patient follow fingers to laterally, including holding at extremes; observe for nystagmus and when it occurs/worsens
- Test of skew: while patient sitting and looking at examiner’s nose or straight ahead, cover and uncover each eye
Positive findings for central etiology are:
- Normal head impulse test: eyes track the nose normally is a sign of central vertigo (vestibulo-ocular reflex preserved)
- Direction changing nystagmus: nystagmus changes direction based on direction eyes are pointed or spontaneous nystagmus that is dominantly vertical or torsional.
- Skew deviation: when left and right eyes are alternately covered, diagonal or vertical eye movement is observed
Investigations
In patients suspected of having central vertigo, a brain MRI is indicated.
References
Tools / Guidelines
John Hopkins - HINTS Exam Video