NeurologyTier 1Disease (DEADMAN)

Vertigo

Description

Illusion of movement (self or environment) from asymmetric vestibular tone
Not "dizziness" - lightheadedness, presyncope and disequilibrium are different problems with different differentials

Classify by timing and trigger, not by quality

"What does it feel like?" is unreliable. "How long, and what brings it on?" is diagnostic.

Syndrome	Duration	Trigger	Typical cause
Triggered episodic	Seconds	Head position change	BPPV, orthostatic hypotension
Spontaneous episodic	Minutes-hours	None	Vestibular migraine, Meniere, TIA, panic
Acute vestibular syndrome	Days-weeks, continuous	None (may follow viral illness)	Vestibular neuritis, posterior circulation stroke, MS
Chronic vestibular syndrome	Months	Motion, visual patterns	Bilateral vestibulopathy, PPPD, cerebellar degeneration

Peripheral vs central

	Peripheral	Central
Nystagmus	Unidirectional, horizontal-torsional, suppressed by fixation	Direction-changing, vertical or pure torsional, not suppressed
Hearing	May be affected (Meniere, labyrinthitis)	Usually spared
Gait	Unsteady but can walk	Cannot stand or walk unaided
Other neuro signs	Absent	Diplopia, dysarthria, dysphagia, limb ataxia, Horner
Head impulse	Abnormal (corrective saccade)	Normal

Epidemiology

Dizziness ~5% of ED presentations; vertigo ~1/4 of those
BPPV commonest peripheral cause - lifetime prevalence ~2.4%, F>M ~2:1, peaks 50-70
Vestibular migraine ~1% population - commonest cause of spontaneous recurrent vertigo, F>M 3:1
Meniere ~0.2%, peak 40-60
~4-5% of isolated acute vertigo in ED is stroke - rises steeply with vascular risk factors and age >60

Aetiopathogenesis

Peripheral (labyrinth / CN VIII)

BPPV - otoconia displaced into semicircular canal (posterior ~85%) -> canalithiasis
Vestibular neuritis - presumed post-viral/HSV-1 reactivation inflammation of vestibular nerve
- Labyrinthitis = same + hearing loss
Meniere - endolymphatic hydrops
Trauma - temporal bone fracture, labyrinthine concussion, perilymph fistula
Vestibular schwannoma (imbalance > true vertigo; unilateral SNHL and tinnitus)
Ototoxicity - aminoglycosides (gentamicin), cisplatin, loop diuretics
Herpes zoster oticus (Ramsay Hunt)

Brainstem / cerebellum

Vascular - PICA/AICA infarct, lateral medullary syndrome, vertebral dissection, cerebellar haemorrhage
Vestibular migraine
Cerebellar or fourth-ventricle tumour
Demyelination (MS plaque at root entry zone)
Chiari malformation, basilar invagination

Temporal lobe / cortical

Ischaemia
Complex partial (focal impaired-awareness) seizures - vertiginous aura, brief, with automatisms

Non-vestibular mimics

Orthostatic hypotension, arrhythmia, anaemia, hypoglycaemia
Drugs - anticonvulsants, benzodiazepines, antihypertensives, alcohol
Anxiety, PPPD

Diagnosis

Bedside tests that decide the answer

A. HINTS - only valid in continuous acute vestibular syndrome with nystagmus

Do NOT apply to episodic vertigo or to a patient without nystagmus.

	Peripheral	Central (any one)
HI - head impulse	Abnormal (catch-up saccade)	Normal
N - nystagmus	Unidirectional	Direction-changing on gaze
TS - test of skew	Absent	Skew deviation present

Add HINTS-plus: new unilateral hearing loss -> central (AICA territory)
Performed by an experienced examiner, more sensitive for stroke than early MRI-DWI (DWI false-negative ~15-20% in first 48 h in posterior fossa)

B. Dix-Hallpike - posterior canal BPPV

Latency 1-5 s, upbeat-torsional nystagmus toward the affected (lower) ear, fatigable, <60 s
Supine roll test if Dix-Hallpike negative -> horizontal canal BPPV

C. Gait

Severe truncal ataxia / inability to stand unsupported = central until proven otherwise - image urgently

Red flags for central cause

Vascular risk factors, age >60, sudden onset
Headache or neck pain (dissection), diplopia, dysarthria, dysphagia, weakness, numbness
Vertical or direction-changing nystagmus, normal head impulse
Cannot walk

Imaging

CT is near-useless for posterior fossa ischaemia - use it only to exclude haemorrhage
MRI brain with DWI + MRA/CTA of vertebrals if central suspected
- Repeat MRI at 48-72 h if initial negative and clinical suspicion persists

Other

Audiometry if any hearing symptom; MRI IAM if asymmetric SNHL (schwannoma)
Vestibular function testing (vHIT, caloric, VEMP) for chronic or unclear cases
ECG, lying/standing BP, glucose when the history suggests presyncope rather than vertigo

Management

By diagnosis

BPPV

Epley (canalith repositioning) for posterior canal - ~80% resolve after 1-2 manoeuvres
Barbecue/Lempert roll for horizontal canal
Vestibular suppressants are not indicated and delay central compensation
Recurrence ~15-30%/yr - teach self-Epley/Brandt-Daroff

Vestibular neuritis

Short course vestibular suppressant (prochlorperazine) for <72 h only
Early vestibular rehabilitation - drives central compensation, the intervention that matters
Steroids: not routinely recommended (no benefit on long-term function)

Vestibular migraine

Acute: triptan may help; treat as migraine
Prophylaxis if frequent: propranolol, amitriptyline, topiramate, candesartan
Trigger and lifestyle management; avoid medication-overuse

Meniere

Salt restriction, avoid caffeine/alcohol/nicotine
Betahistine (evidence weak), thiazide
Refractory: intratympanic steroid; intratympanic gentamicin or labyrinthectomy (ablative - trades vertigo for hearing)

Posterior circulation stroke

Treat as stroke - thrombolysis/thrombectomy pathway, stroke unit, secondary prevention
Cerebellar infarct with mass effect: monitor for hydrocephalus and herniation days 2-5, consider suboccipital decompression

Cross-cutting

Vestibular rehabilitation for any uncompensated peripheral loss
Falls risk assessment, home safety, review sedating drugs
Stop chronic vestibular suppressants - they prevent compensation and cause parkinsonism (prochlorperazine)
Driving advice; occupational restrictions (heights, machinery)

Associations

Migraine - with BPPV, Meniere and PPPD
Anxiety and depression - both cause and consequence; PPPD frequently follows an acute vestibular event
Head trauma - BPPV, labyrinthine concussion
Osteoporosis and vitamin D deficiency - association with BPPV recurrence
Vascular risk factors - posterior circulation ischaemia
Ototoxic drug exposure - aminoglycosides, cisplatin
MS, vestibular schwannoma (NF2), superior canal dehiscence (sound/pressure-induced - Tullio)

Natural history & complications

BPPV - self-limiting over weeks, but recurs in 15-30%/yr; immediate resolution with repositioning
Vestibular neuritis - acute phase 24-72 h, gradual improvement over weeks; central compensation, not recovery of the nerve
- Persistent imbalance in ~10-30%, usually from failed compensation or PPPD
Meniere - fluctuating; vertigo attacks eventually "burn out", leaving permanent low-frequency SNHL and imbalance
Vestibular migraine - episodic over decades, tracks headache activity

Complications

Falls and fracture, particularly in the elderly
Persistent postural-perceptual dizziness (PPPD) - chronic non-spinning dizziness worse with motion and complex visual environments
Hearing loss, tinnitus
Loss of driving/licence and occupational capacity
Missed posterior circulation stroke is the major clinical risk - isolated vertigo with no other signs can be the entire presentation

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