What causes sudden onset of vertigo symptoms?

Causes of Sudden Onset Vertigo

Sudden onset vertigo is most commonly caused by benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Ménière's disease, or vestibular migraine, but can also result from serious conditions like stroke that require immediate medical attention. 1, 2

Differentiating Types of Vertigo

Peripheral Causes (Inner Ear)

1. Benign Paroxysmal Positional Vertigo (BPPV)

   • Brief episodes lasting seconds triggered by head position changes
   • No associated hearing loss, tinnitus, or aural fullness
   • Positive Dix-Hallpike maneuver with characteristic nystagmus
   • Most common cause of recurrent vertigo 1, 3

2. Vestibular Neuritis

   • Sudden severe vertigo lasting 12-36 hours
   • Prolonged nausea and vomiting
   • No hearing loss, tinnitus, or aural fullness
   • Viral etiology affecting vestibular system 1

3. Labyrinthitis

   • Sudden severe vertigo with profound hearing loss
   • Prolonged vertigo (>24 hours)
   • Non-episodic, non-fluctuating symptoms 1

4. Ménière's Disease

   • Recurrent episodes lasting 20 minutes to 12 hours
   • Fluctuating hearing loss, tinnitus, and ear fullness
   • Audiometrically documented low-to-midfrequency sensorineural hearing loss 1

Central Causes (Brain)

1. Stroke/Ischemia (Vertebrobasilar Territory)

   • Sudden onset vertigo lasting minutes
   • May have associated neurological symptoms (dysarthria, dysmetria, dysphagia)
   • Severe postural instability disproportionate to vertigo
   • Nystagmus that doesn't suppress with fixation
   • Accounts for 3-7% of vertigo cases 2, 4

2. Vestibular Migraine

   • Episodes lasting 5 minutes to 72 hours
   • Current or history of migraine
   • Migraine symptoms during at least 50% of dizzy episodes
   • Accounts for approximately 14% of vertigo cases 2

3. Multiple Sclerosis

   • Often progressive fluctuating bilateral hearing loss
   • May present with vision, skin, and joint problems 1

4. Vestibular Schwannoma

   • Chronic imbalance more common than episodic vertigo
   • Asymmetric hearing loss and tinnitus
   • Hearing loss doesn't typically fluctuate 1

Red Flags for Central Vertigo

• Direction-changing nystagmus without head position changes
• Downbeating nystagmus without torsional component
• Gaze-evoked nystagmus that doesn't fatigue
• Additional neurological findings (dysarthria, dysmetria, dysphagia)
• Severe postural instability disproportionate to vertigo
• Failure to respond to repositioning maneuvers 2

Diagnostic Approach

1. Determine if it's true vertigo

   • Confirm patient is describing a false sensation of rotation or spinning
   • Distinguish from lightheadedness or presyncopal episodes 1

2. Assess timing and triggers

   • Spontaneous vs. positionally triggered
   • Duration of episodes (seconds, minutes, hours, days)
   • Single attack vs. recurrent episodes 5

3. Look for associated symptoms

   • Hearing loss, tinnitus, ear fullness (peripheral)
   • Neurological symptoms (central)
   • Headache, photophobia (migraine-associated) 1, 2

4. Perform targeted examination

   • Dix-Hallpike maneuver for BPPV
   • Head impulse test to distinguish vestibular neuritis from cerebellar infarction
   • Nystagmus characteristics (direction, fixation suppression) 2, 3

Important Cautions

1. Don't miss stroke: Cerebellar stroke can mimic peripheral vestibular disorders in approximately 10% of cases. Isolated transient vertigo may precede a vertebrobasilar stroke by weeks or months. 2

2. Beware of vague descriptions: Many patients use "dizziness" to describe various sensations. Ensure you're dealing with true vertigo (spinning sensation) rather than lightheadedness or presyncope. 1

3. Consider age and risk factors: In elderly patients or those with vascular risk factors, maintain a higher suspicion for central causes even with seemingly typical peripheral presentations. 2, 4

4. Watch for atypical features: Neuroimaging should be considered when vertigo presents with atypical features or doesn't respond to appropriate treatment for peripheral causes. 2, 6

By carefully evaluating the pattern, duration, associated symptoms, and examination findings, the cause of sudden vertigo can be determined in most cases, allowing for appropriate treatment and management.