What are the causes of vertigo?

Causes of Vertigo

The most common causes of vertigo are benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Ménière's disease, and vestibular migraine, with BPPV being the single most frequent cause of recurrent vertigo. 1, 2

Classification of Vertigo by Underlying Mechanism

Vertigo can be classified based on whether the cause is peripheral (inner ear) or central (brain):

Peripheral Causes

• Benign Paroxysmal Positional Vertigo (BPPV)

  • Characterized by brief episodes of vertigo triggered by head position changes
  • Positive Dix-Hallpike test with characteristic torsional, upbeating nystagmus
  • Most common cause of recurrent vertigo 1, 3

• Vestibular Neuritis

  • Presents as sudden severe vertigo lasting days
  • Unidirectional horizontal nystagmus
  • Often preceded by viral illness 1, 2

• Ménière's Disease

  • Episodic vertigo with hearing loss, tinnitus, and aural fullness
  • Characteristic audiometric findings
  • Episodes typically last hours 1, 4

• Perilymphatic Fistula

  • Abnormal connection between middle and inner ear
  • Often associated with barotrauma or head injury 2

Central Causes

• Vestibular Migraine

  • Variable duration of vertigo
  • History of migraine headaches
  • Often with photophobia and minimal or absent hearing loss 1

• Cerebrovascular Disease

  • Stroke or TIA affecting posterior circulation
  • Abnormal HINTS examination (Head Impulse, Nystagmus, Test of Skew)
  • Often accompanied by other neurological symptoms 1, 2

• Multiple Sclerosis

  • Central demyelination affecting vestibular pathways
  • Usually accompanied by other neurological symptoms 2

• Intracranial Neoplasms

  • Space-occupying lesions affecting vestibular pathways
  • Progressive symptoms, often with other neurological findings 2

Other Causes

• Psychogenic Vertigo

  • Associated with panic disorder, anxiety disorder, or agoraphobia
  • Often accompanied by other psychological symptoms 4

• Medication-Induced Vertigo

  • Common culprits include sedatives, antihypertensives, and muscle relaxants 1

• Post-Traumatic Vertigo

  • Following head injury, BPPV is the most common cause in younger individuals 3

Modern Approach to Classifying Vertigo

Current guidelines recommend classifying vertigo based on triggers and timing rather than symptom quality 5:

1. Spontaneous Episodic Vestibular Syndrome

   • Vertigo occurring without specific triggers
   • Includes Ménière's disease and vestibular migraine

2. Triggered Episodic Vestibular Syndrome

   • Vertigo provoked by specific actions or positions
   • BPPV is the classic example

3. Acute Vestibular Syndrome

   • Sudden onset of persistent vertigo
   • Includes vestibular neuritis and cerebellar infarction

Red Flags Suggesting Serious Central Causes

• Sudden severe headache
• New neurological symptoms
• Inability to walk or stand
• Persistent vomiting
• Altered mental status
• Nystagmus that does not lessen with visual fixation 1, 2

Diagnostic Approach

The HINTS examination is particularly valuable for differentiating between peripheral and central causes in acute vestibular syndrome, with properly performed HINTS being even more sensitive than early MRI (100% versus 46%) for detecting stroke 1.

For positional vertigo, the Dix-Hallpike maneuver remains the gold standard for diagnosing posterior canal BPPV, while the supine roll test is used for lateral semicircular canal BPPV 1.

Understanding the pattern of vertigo (timing, triggers, and associated symptoms) is crucial for accurate diagnosis and appropriate management of the underlying cause 1, 5.