What are the common causes of vertigo?

Common Causes of Vertigo

The most common causes of vertigo are benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Menière's disease, vestibular migraine, and vascular causes, with BPPV accounting for approximately 42% of cases in primary care settings. 1

Peripheral Causes of Vertigo

Benign Paroxysmal Positional Vertigo (BPPV)

• Most common cause of peripheral vertigo 1
• Characterized by:
  • Brief episodes of vertigo (typically <1 minute)
  • Triggered by specific head position changes
  • No associated hearing loss
  • Positive Dix-Hallpike test with characteristic nystagmus
  • Responds to canalith repositioning procedures

Vestibular Neuritis/Labyrinthitis

• Second most common cause in primary care settings (41%) 1
• Features:
  • Acute onset of persistent vertigo lasting days to weeks
  • Associated with nausea, vomiting, and intolerance to head motion
  • Labyrinthitis includes hearing loss; vestibular neuritis does not
  • Improves with vestibular suppressants initially, followed by vestibular rehabilitation 2

Menière's Disease

• Accounts for approximately 10% of vertigo cases in primary care 1
• Characterized by:
  • Discrete episodic attacks lasting hours
  • Fluctuating hearing loss
  • Aural fullness and tinnitus in the affected ear
  • Often responds to low-salt diet and diuretics 2

Other Peripheral Causes

• Superior canal dehiscence syndrome (SCDS)
  • Vertigo induced by pressure changes, not position changes
  • May present with conductive hearing loss 1
• Perilymph fistula
  • Episodes triggered by pressure changes
  • May have fluctuating hearing loss 1
• Posttraumatic vertigo
  • Various manifestations including vertigo, disequilibrium, tinnitus, and headache
  • Can involve both peripheral and central structures 1

Central Causes of Vertigo

Vestibular Migraine

• Very common with lifetime prevalence of 3.2%
• May account for up to 14% of vertigo cases 1
• Diagnostic criteria:
  • ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours
  • Current or history of migraine
  • ≥1 migraine symptoms during at least 50% of dizzy episodes
  • Other causes ruled out 1
• Typically responds to dietary changes, tricyclic antidepressants, beta blockers or calcium channel blockers 2

Cerebrovascular Disorders

• Brainstem and cerebellar stroke/TIA
  • Can mimic peripheral vestibular disorders (10% of cerebellar strokes) 1
  • More sudden onset than vestibular neuritis
  • Often has associated neurological findings
  • Isolated transient vertigo can precede stroke in vertebrobasilar artery 1
  • Attacks typically last <30 minutes without hearing loss
  • Nystagmus doesn't fatigue and isn't suppressed by gaze fixation 1

Other Central Causes

• Multiple sclerosis
• Intracranial tumors
• Demyelinating diseases
• Central positional vertigo (rare)
  • Nystagmus is typically purely vertical (upbeating or downbeating) 3
  • Usually has associated neurological findings

Psychiatric/Other Causes

• Anxiety and panic disorders
• Medication side effects
• Postural hypotension
• Cervicogenic vertigo

Distinguishing Central from Peripheral Vertigo

Key Clinical Features Suggesting Central Vertigo 1:

• Downbeating nystagmus on Dix-Hallpike maneuver
• Direction-changing nystagmus without changes in head position
• Gaze-evoked or direction-switching nystagmus
• Baseline nystagmus without provocative maneuvers
• Severe postural instability
• Associated neurological signs (dysarthria, dysmetria, dysphagia, sensory/motor deficits)
• Failure to respond to conservative management

Clinical Approach to Diagnosis

1. Categorize dizziness based on timing and triggers 1:

   • Acute vestibular syndrome (continuous dizziness lasting days to weeks)
   • Triggered episodic vestibular syndrome (brief episodes triggered by position changes)
   • Spontaneous episodic vestibular syndrome (untriggered episodes lasting minutes to hours)
   • Chronic vestibular syndrome (dizziness lasting weeks to months)

2. For positional vertigo:

   • Perform Dix-Hallpike test for posterior canal BPPV
   • Perform supine roll test for horizontal canal BPPV
   • Note that central positional vertigo typically presents with purely vertical nystagmus 3

3. For suspected central causes:

   • MRI is indicated in any patient with acute vertigo and profound imbalance suspected to be cerebellar infarct or hemorrhage 3
   • Look for associated neurological signs

Important Caveats

• BPPV is often underdiagnosed or misdiagnosed despite being the most common cause 1
• Cerebellar stroke can sometimes present similar to peripheral vestibular disorders with vertigo as the only initial symptom 1, 4
• Duration of attacks helps distinguish causes: vertebrobasilar insufficiency typically lasts minutes, while peripheral inner ear causes typically last hours 3
• Failure to respond to appropriate treatment for presumed peripheral vertigo should prompt investigation for central causes 1
• Patients with risk factors for cerebrovascular disease who present with acute vertigo should be evaluated for stroke even without obvious neurological signs 4