What are the causes of vertigo?

Causes of Vertigo

The most common causes of vertigo include benign paroxysmal positional vertigo (BPPV), vestibular neuritis, and Ménière's disease, but clinicians must also consider central causes such as stroke, vestibular migraine, and multiple sclerosis. 1, 2

Classification of Vertigo by Timing and Triggers

Vertigo can be classified into three main categories based on timing and triggers:

1. Acute Vestibular Syndrome (continuous vertigo lasting days)

   • Vestibular neuritis
   • Labyrinthitis
   • Posterior circulation stroke
   • Demyelinating diseases
   • Posttraumatic vertigo

2. Triggered Episodic Vestibular Syndrome (brief episodes with specific triggers)

   • BPPV
   • Postural hypotension
   • Perilymph fistula
   • Superior canal dehiscence syndrome

3. Spontaneous Episodic Vestibular Syndrome (recurrent episodes without clear triggers)

   • Vestibular migraine
   • Ménière's disease
   • Posterior circulation TIA
   • Medication side effects
   • Anxiety or panic disorder

Peripheral Causes of Vertigo

Benign Paroxysmal Positional Vertigo (BPPV)

• Presentation: Brief episodes (seconds) of vertigo triggered by head position changes
• Key features: Positive Dix-Hallpike test with characteristic nystagmus
• Differentiating factor: Not associated with hearing loss, tinnitus, or aural fullness 1

Ménière's Disease

• Presentation: Episodes lasting 20 minutes to 12 hours
• Key features: Fluctuating low to mid-frequency sensorineural hearing loss, tinnitus, aural fullness
• Diagnostic criteria: Two or more spontaneous vertigo attacks with documented hearing loss and fluctuating aural symptoms 1

Vestibular Neuritis

• Presentation: Acute prolonged vertigo (12-36 hours) with prolonged nausea and vomiting
• Key features: No hearing loss, tinnitus, or aural fullness
• Differentiating factor: Single prolonged episode rather than recurrent episodes 1

Labyrinthitis

• Presentation: Sudden severe vertigo with profound hearing loss
• Key features: Vertigo lasting >24 hours, not episodic or fluctuating
• Differentiating factor: Associated hearing loss distinguishes from vestibular neuritis 1

Other Peripheral Causes

• Perilymph fistula: Pressure-triggered episodes of vertigo, may have fluctuating hearing loss 1
• Superior canal dehiscence syndrome: Pressure or sound-induced vertigo and oscillopsia 1
• Otosyphilis: Sudden unilateral or bilateral fluctuating sensorineural hearing loss with tinnitus and/or vertigo 1
• Posttraumatic vertigo: Various manifestations following head trauma 1

Central Causes of Vertigo

Vestibular Migraine

• Presentation: Attacks lasting 5 minutes to 72 hours
• Key features: Current or history of migraine, migraine symptoms during ≥50% of dizzy episodes
• Differentiating factor: Associated migraine symptoms (headache, photophobia, phonophobia) 1

Stroke/Cerebrovascular Disease

• Presentation: Sudden onset vertigo, may last minutes with nausea, vomiting, severe imbalance
• Key features: May have visual blurring and drop attacks
• Red flags: Abnormal nystagmus patterns (downbeating, direction-changing without head position changes), associated neurological symptoms (dysarthria, dysmetria, dysphagia, sensory/motor deficits) 1, 3
• Important note: Approximately 10% of cerebellar strokes can present similar to peripheral vestibular disorders 1, 3

Multiple Sclerosis and Other Demyelinating Diseases

• Presentation: Often progressive fluctuating bilateral hearing loss that is steroid-responsive
• Key features: May present with vision, skin, and joint problems 1

Vestibular Schwannoma

• Presentation: May present with vertigo but more commonly chronic imbalance
• Key features: Asymmetric hearing loss and tinnitus
• Differentiating factor: Hearing loss typically does not fluctuate 1

Other Causes of Vertigo

Anxiety or Panic Disorder

• Presentation: Lightheadedness and dizziness
• Key features: May have hyperventilation, but can also have true vestibular dysfunction 1

Medication Side Effects

• Common culprits: Anticonvulsants (Mysoline, carbamazepine, phenytoin), antihypertensives, cardiovascular medications 1

Cervicogenic Vertigo

• Presentation: Vertigo associated with degenerative cervical spine disease
• Key features: Triggered by rotation of head relative to body while upright (different from BPPV) 1

Postural Hypotension

• Presentation: Episodic dizziness or vertigo
• Key features: Provoked by moving from supine to upright position 1

Diagnostic Approach

1. Determine if it's true vertigo (illusion of movement)
2. Classify based on timing and triggers (acute, triggered episodic, or spontaneous episodic)
3. Differentiate peripheral from central causes through:
   • Nystagmus characteristics (direction, duration, fatigability)
   • Associated symptoms (hearing loss, neurological deficits)
   • Response to positional testing

Clinical Pearls

• Nystagmus that does not lessen with visual fixation suggests a central cause 4
• Failure to respond to repositioning maneuvers or vestibular rehabilitation should raise suspicion for central causes 1
• Always consider the possibility of multiple concurrent vestibular disorders in patients with mixed clinical presentations 1
• Isolated transient vertigo may precede a vertebrobasilar stroke by weeks or months 1

Remember that while most cases of vertigo are benign peripheral disorders, careful evaluation is essential to identify potentially serious central causes that require urgent intervention.