Causes of Vertigo
The most common causes of vertigo are benign paroxysmal positional vertigo (BPPV), vestibular neuritis, and Menière's disease, with BPPV being the most frequent peripheral cause, accounting for approximately 42% of vertigo cases in non-specialty settings. 1, 2
Peripheral Causes of Vertigo
Benign Paroxysmal Positional Vertigo (BPPV)
- Characterized by brief episodes of vertigo triggered by changes in head position
- Diagnosed with the Dix-Hallpike maneuver (gold standard for posterior canal BPPV) or supine roll test (for lateral canal BPPV) 2
- Caused by detached otoconia (calcium carbonate crystals) in the semicircular canals 3
- Presents with positional vertigo lasting seconds with a positive Dix-Hallpike test 2
Vestibular Neuritis
- Presents with sudden, severe vertigo lasting days
- Associated with unidirectional horizontal nystagmus
- No hearing loss or other neurological symptoms 2
Menière's Disease
- Characterized by episodic vertigo with hearing loss, tinnitus, and aural fullness
- Diagnostic features include characteristic audiometric findings 2
- Accounts for approximately 10% of vertigo cases in non-specialty settings (up to 43% in subspecialty settings) 1
Central Causes of Vertigo
Migraine-Associated Vertigo
- Common cause accounting for up to 14% of vertigo cases 1
- Diagnostic criteria include:
- Distinguished from BPPV by the presence of migraine/headache components 1
Vertebrobasilar Insufficiency
- Can present with isolated attacks of vertigo that may precede stroke by weeks or months
- Vertigo attacks typically last less than 30 minutes without associated hearing loss
- Distinguished from BPPV by nystagmus type, severity of postural instability, and presence of additional neurological signs 1
Other Central Causes
- Multiple sclerosis
- Intracranial tumors
- Neurodegenerative disorders 4
- Cerebrovascular disorders related to vertebrobasilar circulation 4
Distinguishing Central from Peripheral Vertigo
Red Flags for Central Causes
- Down-beating nystagmus on the Dix-Hallpike maneuver
- Direction-changing nystagmus without changes in head position
- Baseline nystagmus without provocative maneuvers
- Nystagmus that does not lessen when the patient focuses 1, 5
- Associated neurological deficits
- Sudden severe headache with dizziness
- Inability to walk or stand
- Persistent vomiting with dizziness
- Altered mental status 2
Other Causes of Vertigo
Medication-Induced Vertigo
- Common culprits include sedatives, antihypertensives, and muscle relaxants 2
- Medication review and deprescribing when possible is recommended, especially in seniors
Psychophysiologic Causes
- Often associated with anxiety, depression, and panic disorder 4
- Should be considered when other causes have been ruled out
Post-Traumatic Vertigo
- BPPV is the most common cause of vertigo following head injury in younger individuals 3
Diagnostic Approach
When evaluating a patient with vertigo, it's crucial to:
- Determine if the patient truly has vertigo (illusion of rotation) versus other forms of dizziness
- Distinguish between peripheral and central causes
- Identify specific diagnosis through characteristic clinical features
The history (timing, duration, triggers, associated symptoms) and physical examination (especially neurological examination and special tests like the Dix-Hallpike maneuver) are essential for accurate diagnosis 5.
Important Caveats
- BPPV is often underdiagnosed or misdiagnosed despite being the most common cause of peripheral vertigo 1
- Central causes account for approximately 25% of dizziness cases and must not be missed 4
- Posterior circulation ischemia rarely causes isolated vertigo attacks; when it does, the attacks are typically brief and frequent with a short history 6
- Exercise caution when performing positional tests in patients with cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, Down syndrome, severe rheumatoid arthritis, cervical radiculopathies, Paget's disease, ankylosing spondylitis, low back dysfunction, spinal cord injuries, and morbid obesity 1