What are the causes and treatments of vertigo?

Causes and Management of Vertigo

Benign Paroxysmal Positional Vertigo (BPPV), vestibular neuritis, and Menière's disease are the most common causes of vertigo, accounting for over 75% of cases, with BPPV being the predominant cause in non-specialty settings (42% of cases). 1, 2

Common Causes of Vertigo

Peripheral Causes

• BPPV (42% in non-specialty settings) 1

  • Characterized by brief episodes of vertigo triggered by head position changes
  • Diagnosed with Dix-Hallpike maneuver (gold standard) showing torsional, upbeating nystagmus
  • Treatment: Canalith repositioning procedures (Epley or Semont maneuvers)

• Vestibular Neuritis (41% in non-specialty settings) 1

  • Presents with sudden, severe vertigo lasting days
  • Associated with unidirectional horizontal nystagmus
  • Treatment: Brief use of vestibular suppressants, vestibular rehabilitation

• Menière's Disease (10% in non-specialty settings, up to 43% in specialty settings) 1

  • Episodic vertigo with hearing loss, tinnitus, and aural fullness
  • Treatment: Low-salt diet, diuretics, intratympanic medications for refractory cases

• Post-traumatic Vertigo 1

  • Various manifestations including vertigo, disequilibrium, tinnitus, headache
  • Traumatic brain injury can cause BPPV

Central Causes

• Migraine-Associated Vertigo (14% of vertigo cases) 1, 2

  • Diagnostic criteria: episodic vestibular symptoms, migraine diagnosis, and at least two migraine symptoms during vertiginous episodes
  • Treatment: Migraine-specific medications (triptans), prophylactic therapy (calcium channel antagonists, tricyclic antidepressants, beta-blockers)

• Vertebrobasilar Insufficiency 1, 2

  • Isolated attacks of vertigo lasting <30 minutes without hearing loss
  • May precede stroke by weeks/months
  • Nystagmus doesn't fatigue and isn't easily suppressed by gaze fixation
  • Up to 25% of Acute Vestibular Syndrome cases may be due to stroke (75% in high vascular risk patients)

• Intracranial Tumors 1

  • Persistent symptoms with neurological progression
  • May have baseline nystagmus without provocative maneuvers

• Multiple Sclerosis 3

  • Consider in younger patients with neurological symptoms

• Psychological Causes 3, 4

  • Associated with panic disorder, anxiety disorder, agoraphobia
  • Treatment: Benzodiazepines

Diagnostic Approach

Differentiating Peripheral vs. Central Vertigo

1. HINTS Examination 2

   • Head Impulse, Nystagmus, Test of Skew
   • 100% sensitivity for detecting stroke (vs. 46% for early MRI)
   • Abnormal HINTS exam is key for diagnosing central vertigo

2. Nystagmus Patterns 1, 5

   • Central causes: Down-beating nystagmus on Dix-Hallpike, direction-changing nystagmus without head position changes, baseline nystagmus
   • Peripheral causes: Unidirectional horizontal nystagmus (vestibular neuritis), positional torsional nystagmus (BPPV)

3. VAIN Triad 2

   • Vertigo-Ataxia, Incessant, or Non-positional
   • 100% sensitivity for central vertigo (66.4% specificity)

Red Flags Requiring Immediate Evaluation 2

• Sudden severe headache with dizziness
• New neurological symptoms
• Inability to walk or stand
• Persistent vomiting with dizziness
• Somnolence or altered mental status

Treatment Approaches

Medication Management

• Meclizine 6

  • Indicated for vertigo associated with vestibular system diseases
  • Dosage: 25-100 mg daily in divided doses
  • Side effects: Drowsiness, dry mouth, potential anticholinergic effects

• Other Pharmacological Options 4

  • Anticholinergics, antihistamines: Modify symptom intensity
  • Benzodiazepines: Useful for vestibular suppression and psychological vertigo
  • Calcium channel antagonists: Effective for vestibular migraine

Non-Pharmacological Management

• Canalith Repositioning Procedures 2, 7

  • Epley or Semont maneuvers for posterior canal BPPV
  • Specific maneuvers based on canal involvement

• Vestibular Rehabilitation Therapy 2

  • First-line for central vestibulopathy
  • Activates central neuroplastic mechanisms
  • Achieves adaptive compensation of impaired vestibular functions

Imaging Considerations

• MRI Brain 2

  • Preferred for suspected central vertigo
  • Indicated for:
    • Acute Vestibular Syndrome with abnormal HINTS exam
    • Neurological deficits
    • High vascular risk patients
    • Chronic undiagnosed dizziness not responding to treatment

• CT Temporal Bone 2

  • Useful for assessing bony abnormalities
  • Recommended without contrast for peripheral vertigo evaluation

Important Clinical Pitfalls

• BPPV is often underdiagnosed or misdiagnosed despite being the most common cause 1
• CT head may miss strokes in vertigo patients; MRI is more sensitive 2
• One-third to two-thirds of posterior circulation stroke patients may lack focal neurologic signs 2
• Vestibular suppressants should be used briefly in vestibular neuritis to avoid interfering with compensation 4
• Patients with high Sudbury Vertigo Risk Score (>8) have 41% risk of serious underlying pathology and require urgent neuroimaging 2