Vertigo

Last updated: March 23, 2022

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Vertigo is the false sensation of motion (e.g., spinning or swaying) caused by dysfunction of the inner ear (peripheral vertigo) or the central vestibular system (central vertigo). It is often confused with similar terms related to dizziness (e.g., disequilibrium, lightheadedness). Peripheral causes (e.g., benign paroxysmal positional vertigo, vestibular neuritis) are typically benign, while central causes (e.g., posterior stroke, tumors of the posterior fossa) can be life-threatening. Clinical features and neurological examination findings can help identify the underlying cause. Depending on the clinical presentation, targeted examination maneuvers may also be indicated. In patients with episodic, triggered vertigo, the Dix-Hallpike maneuver can be used to confirm benign paroxysmal positional vertigo (BPPV), while in patients with acute vertigo without a clear trigger, head impulse, nystagmus, test of skew (HINTS) examination can be used to assess for central causes (e.g., ischemic stroke). Urgent neuroimaging is indicated in patients with suspected central vertigo. Further testing, including laboratory studies, is not routinely required. Treatment depends on the underlying cause.

See also “Vestibular neuritis”, “Labyrinthitis”, “BPPV”, and “Meniere disease.”

  • Vertigo: the sensation of spinning or swaying of oneself (internal vertigo) or of one's surroundings (external vertigo) while stationary; caused by vestibular dysfunction due to asymmetric vestibular input and may be spontaneous or triggered [1][2]
  • Dizziness [1][2]
    • A nonvertiginous disturbance in spatial orientation without a false sensation of motion
    • Often used by patients as an umbrella term to describe a variety of sensations, including vertigo, presyncope, imbalance, and confusion [3]

Do not confuse vertigo for presyncope, which refers to severe lightheadedness or near loss of consciousness; most commonly due to a drop in systemic blood pressure or hypoxia. [3][4]

Vertigo can be caused by a variety of medical conditions, which are commonly divided into central and peripheral causes based on the location of involvement.

Stroke and acute obstructive hydrocephalus caused by a posterior fossa tumor are medical emergencies and require immediate management.

Vertigo is often accompanied by other signs and symptoms, which can help to identify the underlying cause. However, further evaluation is often necessary to establish a diagnosis and rule out life-threatening causes.

Clinical features alone cannot determine whether vertigo is peripheral or central in origin, as symptoms often overlap, e.g., movement can worsen symptoms of dizziness and/or vertigo in both peripheral and central causes. [4]

Associated features

Peripheral vs. central vertigo [4][6][8]
Clinical features Suggestive of peripheral vertigo Suggestive of central vertigo
Neurological features

Cranial nerve features

Cerebellar features

Nystagmus [4][9]

(See “HINTS exam” for details.)

  • Unidirectional, frequently horizontal
  • Horizontal, torsional, or vertical (e.g., down-beat nystagmus)
Hearing loss and/or tinnitus
  • Common
  • Rare [10]

Other focal neurological deficits

  • Absent
  • Present

Sense of motion (e.g., swaying, spinning)

  • Severe
  • Mild
Nausea and/or vomiting
  • Severe
  • Varies

Any of the Dangerous D's (Dysphagia, Dysarthria, Diplopia, Dysmetria) strongly suggest a central cause of vertigo.

Vestibular syndromes

Patients are often classified into vestibular syndromes based on their clinical presentation (e.g., onset, triggers, and chronicity) in order to guide the diagnostic evaluation (e.g., Dix-Hallpike testing vs HINTS examination).

  • Acute vestibular syndrome: the acute onset of continuous vertigo, gait instability, nystagmus, and nausea (with or without hearing loss) that may be worsened, but not triggered, by movement; usually lasts days to weeks [3][8][11]
  • Episodic vestibular syndrome: recurrent episodes of vertigo often associated with gait instability and nausea that typically last seconds to hours; may be triggered or spontaneous [3]
  • Chronic vestibular syndrome: the presence of continuous vestibular symptoms for weeks to years [3]

Clinical evaluation [2][3][4]

When approaching a patient with vertigo, think TiTrATE: Timing, Triggers, And Targeted Examination. [3]

Diagnostic approach

Consider further diagnostic studies depending on the suspected underlying disease or if the cause is still unknown; see “Diagnostic testing in vertigo” for details.

Obtain immediate neuroimaging to evaluate for central causes in patients with acute vertigo and focal neurological deficits and/or abnormal HINTS testing, especially if risk factors for ischemic stroke are present.

Head impulse, nystagmus, test of skew (HINTS) examination [8][11]

Performing HINTS testing while the patient is asymptomatic increases the likelihood of a false-negative result. [8][13]

Overview of HINTS examination [8][11][14]
Procedure

Findings

Suggestive of a peripheral cause Suggestive of a central cause [8]

Head impulse test

Evaluates the vestibuloocular reflex (VOR) [15]

  • Ask the patient to fixate on a stationary object in front of them.
  • Rapidly rotate the patient's head 10 degrees from center and assess their ability to maintain a central gaze. [4]
  • Repeat the procedure, rotating the patient's head to the contralateral side.
  • Abnormal head impulse test (impaired VOR)
    • Inability to maintain central fixation on a stationary target during head rotation
    • Followed by a corrective shift of the eyes back to the stationary target (correction saccade)

Nystagmus [15]

  • Spontaneous horizontal nystagmus (typical) [13]
  • The direction of nystagmus does not change with gaze change (unidirectional nystagmus).
  • The fast phase beats away from the side of the lesion.
  • Intensity increases when the patient looks toward the fast phase and decreases when looking toward the slow phase (Alexander law).
  • Gaze fixation suppresses nystagmus.

Test of skew

  • Ask the patient to maintain a fixed central gaze and to keep both eyes open during the examination.
  • Repeatedly cover and uncover alternating eyes, while watching for vertical deviation from the central gaze upon uncovering the eye. [4]
Interpretation [10][12]

During HINTS testing, think INFARCT to identify central causes (e.g., stroke): Impulse Normal, Fast-phase Alternating, Refixation on Cover Test. [10]

Neuroimaging [2][8][16]

Neuroimaging is indicated if clinical findings raise suspicion for a central cause of vertigo (e.g., cerebellar stroke, lateral medullary syndrome), especially in patients with any risk factors for ischemic stroke (e.g., age ≥ 65 years, multiple comorbidities).

Additional studies [2]

Additional studies may be performed if the cause of vertigo remains unknown or if patient history and/or physical examination suggest an alternative cause.

The direction of the fast component of the physiological nystagmus elicited with caloric testing can be remembered with the term COWS: Cold Opposite; Warm Same.

Etiology [2][4]

Causes of peripheral vertigo
Characteristics of vertigo Clinical features Diagnostic approach
Vestibular neuritis and labyrinthitis
Benign paroxysmal positional vertigo
Meniere disease

Management of peripheral vertigo

For detailed management of specific types of peripheral vertigo, see “Vestibular neuritis”, “Labyrinthitis”, “BPPV”, and “Meniere disease.”

  • Identify and treat the underlying condition; based on clinical evaluation (e.g., Epley maneuver for suspected BPPV).
  • Consider short-term symptomatic pharmacotherapy for acute vertigo, nausea, and vomiting. [22][23][24]
  • if the diagnosis is unclear or a trial of therapy is unsuccessful, consider further diagnostics for vertigo and outpatient follow-up with specialist (e.g., ENT).
  • Consider vestibular rehabilitation therapy to help facilitate central vestibular compensation and accelerate recovery.

Vestibular suppressants [13][14][22][23][24]

Vestibular suppressants should only be used for short periods of time. Chronic use of vestibular suppressants is contraindicated because they can inhibit central compensation and potentially exacerbate chronic gait and postural instability. [13][22][23]

Counsel patients about potential adverse effects of vestibular suppressants (e.g., falls, cognitive dysfunction, drowsiness).

Vestibular rehabilitation [14][22][23]

Etiology [2][4]

Focal neurological deficits are typically present in central causes of vertigo and vary depending on the location of the lesion and/or dysfunction. Neurological examination may show cranial nerve involvement, which is suggestive of brainstem involvement, and/or signs of cerebellar dysfunction.

Causes of central vertigo
Characteristics of vertigo Clinical features Diagnostic approach

Brain ischemia (i.e., stroke, TIA) [25]

Migraine

[6]

Demyelination (e.g., multiple sclerosis) [6]
  • Presentation varies; typically episodic [6]

Continuous, progressive vertigo followed by features of ↑ ICP may suggest life-threatening complications (e.g., cerebellar tonsillar herniation) of posterior fossa tumors (e.g., vestibular schwannoma, meningioma). Obtain immediate neuroimaging and consult neurosurgery. [3][26]

Management of central vertigo

Consider patients with acute vestibular syndrome and HINTS testing that suggests a central cause of vertigo to have a posterior fossa stroke until proven otherwise. [27]

This section lists common mimics of vertigo. For a comparison of different etiologies of vertigo, see “Causes of peripheral vertigo” and “Causes of central vertigo.”

Cardiac and neurological disorders

Other causes of dizziness

Motion sickness [29][30]

  • Definition: a nonpathological acute condition characterized by dizziness, nausea, and autonomic symptoms caused by a mismatch in proprioceptive signals; depending on the means of locomotion, motion sickness is often referred to as seasickness, carsickness, or airsickness.
  • Epidemiology: more frequent in children, women, and individuals with migraines and/or vestibular disorders
  • Etiology: locomotion by any means of transportation (esp. boat) or a simulation thereof (e.g., while watching a film or playing video games)
  • Pathophysiology
    • A mismatch of sensorial information that occurs when parts of the sensory apparatus report motion while others report being stationary
    • Example: reading while driving; the eyes will report being stationary while the vestibular apparatus will report motion or, conversely, while watching a roller coaster simulation, the eyes will report motion, but the vestibular system will report being stationary
  • Clinical features
  • Diagnostics
  • Prevention and treatment
    • Behavioral measures: avoid reading or watching videos and choose a forward-facing seat during transportation, focus the distant horizon, reduce head and body movements
    • Medical treatment: most effective when used prophylactically

Motion sickness can be prevented by suppressing vestibular pathways. Hence, anticholinergics and first-generation antihistamines are the first-line drugs for prevention.

The differential diagnoses listed here are not exhaustive.

Dizziness and vertigo in older adults [28][31]

Dizziness and unsteady gait are abnormal in older patients and should always be thoroughly investigated.

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