What causes severe vertigo?

Causes of Severe Vertigo

The most common causes of severe vertigo include benign paroxysmal positional vertigo (BPPV), Ménière's disease, vestibular neuritis/labyrinthitis, vestibular migraine, stroke/vertebrobasilar insufficiency, and medication side effects. 1

Peripheral Vestibular Causes

• Benign Paroxysmal Positional Vertigo (BPPV): Characterized by brief episodes of vertigo (seconds) triggered by specific head positions. It's the most common cause of peripheral vertigo and results from otoconia (calcium carbonate crystals) dislodging within the semicircular canals. 1, 2

• Ménière's Disease: Features episodic vertigo lasting hours with fluctuating hearing loss, tinnitus, and aural fullness. The attacks are spontaneous rather than positionally triggered. 1, 3

• Vestibular Neuritis/Labyrinthitis: Presents with sudden severe vertigo lasting >24 hours with profound nausea and vomiting. Labyrinthitis includes hearing loss while vestibular neuritis does not. Often attributed to viral infections. 1, 3

• Posttraumatic Vertigo: Can present with various manifestations including vertigo, disequilibrium, tinnitus, and headache. Trauma can also trigger BPPV, which may be more resistant to treatment than idiopathic cases. 1

• Perilymphatic Fistula: Abnormal communication between the middle and inner ear causing triggered episodic vertigo. 1, 4

• Superior Canal Dehiscence Syndrome: Causes triggered episodic vertigo due to a defect in the bone covering the superior semicircular canal. 1

Central Nervous System Causes

• Vestibular Migraine: Features attacks lasting minutes to hours or even >24 hours. Distinguished by migraine history and more photophobia than visual aura. Hearing loss is less likely than in Ménière's disease. 1

• Stroke/Vertebrobasilar Insufficiency: Can cause vertigo lasting minutes with nausea, vomiting, severe imbalance, and visual blurring. Isolated transient vertigo may precede a stroke in the vertebrobasilar artery by weeks or months. The nystagmus doesn't fatigue and isn't easily suppressed by gaze fixation. 1, 5

• Multiple Sclerosis/Demyelinating Diseases: May present with progressive fluctuating bilateral hearing loss alongside vertigo and vision problems. 1, 5

• Central Nervous System Lesions: Various lesions in the brainstem or cerebellum can cause vertigo. 1, 6

Other Causes

• Medication Side Effects: Several medications can cause vertigo including aminoglycosides (like gentamicin), anticonvulsants (Mysoline, carbamazepine, phenytoin), antihypertensives, and cardiovascular medications. 1, 7

• Psychological Disorders: Panic disorder, anxiety disorder, or agoraphobia may present with symptoms of lightheadedness and dizziness that can mimic vertigo. 1, 4

• Cervical Vertigo: Associated with degenerative cervical spine disease. Symptoms are triggered by rotation of the head relative to the body while in an upright posture. 1

• Postural Hypotension: Causes episodic dizziness or vertigo when moving from supine to upright position. 1

• Autoimmune Disorders: Can cause progressive fluctuating bilateral hearing loss with vertigo. May present with vision, skin, and joint problems. 1

• Infectious Causes: Including Lyme disease and viral/bacterial infections that can lead to complete hearing loss and vestibular crisis with prolonged vertigo. 1

Diagnostic Considerations

• Timing and triggers are crucial for differential diagnosis:

  • BPPV: Brief episodes triggered by head position changes 1
  • Ménière's disease: Spontaneous episodes lasting hours 1
  • Vestibular neuritis: Sudden onset, prolonged symptoms 1
  • Stroke: May have additional neurological symptoms 1, 5

• When patients report both vertigo and vision changes, this may help differentiate central from peripheral causes:

  • Visual blurring is particularly common in stroke-related vertigo 5
  • Vestibular migraine features more photophobia 1, 5

• The presence of nystagmus that doesn't lessen with visual fixation suggests a central cause requiring further investigation. 1, 6

Common Pitfalls

• Failure to recognize that multiple vestibular disorders may coexist in the same patient. For example, BPPV can occur in conjunction with Ménière's disease or vestibular neuritis. 1

• Not considering medication side effects as a potential cause of vertigo. Always review the patient's medication list, particularly for anticonvulsants, antihypertensives, and cardiovascular medications. 1, 7

• Overlooking potentially serious central causes like vertebrobasilar insufficiency when symptoms appear to be consistent with more benign conditions. 1, 6

• Misdiagnosing psychological disorders as the primary cause without ruling out underlying vestibular pathology. 1, 4