What are the causes of vertigo?

Causes of Vertigo

Vertigo is primarily caused by peripheral vestibular disorders, central nervous system disorders, or other medical conditions that affect the balance system. 1, 2

Peripheral Vestibular Causes

• Benign Paroxysmal Positional Vertigo (BPPV): The most common cause, characterized by brief episodes (seconds) of vertigo triggered by specific head positions, not associated with hearing loss, tinnitus, or aural fullness 1, 2

• Ménière's Disease: Features episodic vertigo lasting hours with fluctuating hearing loss, tinnitus, and aural fullness; attacks are spontaneous rather than positionally triggered 1, 2

• Vestibular Neuritis/Labyrinthitis: Presents with sudden severe vertigo with prolonged duration (>24 hours), profound nausea, vomiting; labyrinthitis includes hearing loss while vestibular neuritis does not 1, 2

• Posttraumatic Vertigo: Various manifestations including vertigo, disequilibrium, tinnitus, and headache following head trauma 1, 2

• Perilymphatic Fistula: Abnormal communication between middle and inner ear causing pressure-triggered episodic vertigo 1, 2

• Superior Canal Dehiscence Syndrome: Causes pressure-related triggered episodic vertigo due to a defect in the bone covering the superior semicircular canal 1, 3

• Infectious Causes: Including Lyme disease, viral (adenovirus) or bacterial (staph/strep) infections that can lead to complete hearing loss and vestibular crisis with prolonged vertigo 1, 2

• Otosyphilis: Presents with sudden unilateral or bilateral sensorineural fluctuating hearing loss, tinnitus, and/or vertigo 1

Central Nervous System Causes

• Vestibular Migraine: Attacks lasting minutes to hours or even >24 hours, distinguished by migraine history and more photophobia than visual aura 1, 2

• Stroke/Vertebrobasilar Insufficiency: Vertigo may last minutes with nausea, vomiting, severe imbalance, and visual blurring; often accompanied by other neurological symptoms like dysphagia, dysphonia 1, 2

• Multiple Sclerosis/Demyelinating Diseases: May present with vertigo along with other neurological symptoms 1, 2

• Central Nervous System Lesions: Including tumors such as vestibular schwannoma (acoustic neuroma), which typically presents with chronic imbalance, asymmetric hearing loss, and tinnitus rather than episodic vertigo 1, 2

Other Causes

• Medication Side Effects: Including aminoglycosides, anticonvulsants, antihypertensives, and cardiovascular medications 1, 2, 4

• Psychological Disorders: Anxiety, panic disorder, or agoraphobia may present with symptoms of lightheadedness and dizziness that can mimic vertigo 1, 2, 4

• Cervical Vertigo: Associated with degenerative cervical spine disease, with symptoms triggered by rotation of the head relative to the body while in an upright posture 1, 3

• Postural Hypotension: Causes episodic dizziness when moving from supine to upright position 1, 3

Differentiating Features

Timing and Triggers

• Brief episodes (seconds) triggered by head position changes suggest BPPV 1, 3
• Spontaneous episodes lasting hours suggest Ménière's disease or vestibular migraine 1
• Sudden onset and prolonged symptoms (>24 hours) suggest vestibular neuritis or labyrinthitis 1, 3
• Pressure-induced symptoms suggest perilymph fistula or superior canal dehiscence 1, 2

Associated Symptoms

• Hearing loss, tinnitus, aural fullness suggest Ménière's disease or labyrinthitis 1, 3
• Headache, photophobia, phonophobia suggest vestibular migraine 1, 2
• Additional neurological symptoms (dysarthria, dysmetria, dysphagia, sensory/motor loss) suggest stroke or other central causes 1, 2

Nystagmus Characteristics

• Peripheral causes: Typically have nystagmus that fatigues, is suppressed by visual fixation, and changes direction with head position 1
• Central causes: Nystagmus that doesn't fatigue, isn't easily suppressed by visual fixation, may be direction-changing without head position changes, or downbeating without torsional component 1, 2

Clinical Pitfalls to Avoid

• Failing to distinguish between true vertigo (sensation of rotation) and non-specific dizziness, which can lead to misdiagnosis 1
• Overlooking potentially serious central causes like stroke, especially in patients with vascular risk factors 1, 2
• Missing concurrent diagnoses, as BPPV can occur alongside other vestibular disorders like Ménière's disease or vestibular neuritis 1
• Assuming all positional vertigo is BPPV without considering central causes of positional vertigo 1
• Relying solely on symptom description without considering timing, triggers, and associated symptoms for differential diagnosis 1, 2