From the Guidelines
Dizziness can arise from both peripheral and central causes, with peripheral causes including benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Meniere's disease, and labyrinthitis, and central causes including stroke, multiple sclerosis, vestibular migraine, and tumors affecting the brainstem and cerebellum, as noted in the clinical practice guideline for Meniere's disease 1. The most recent and highest quality study, a clinical practice guideline published in 2020, highlights the importance of distinguishing between peripheral and central causes of vertigo to ensure appropriate management and identify potentially serious conditions requiring urgent intervention 1. Some key peripheral causes of vertigo include:
- Benign paroxysmal positional vertigo (BPPV), which occurs when calcium crystals in the inner ear become dislodged, causing brief episodes of vertigo with position changes
- Vestibular neuritis, which involves inflammation of the vestibular nerve, often following a viral infection
- Meniere's disease, which presents with episodes of vertigo, fluctuating hearing loss, tinnitus, and ear fullness due to endolymphatic hydrops
- Labyrinthitis, which is characterized by sudden severe vertigo with profound hearing loss and prolonged vertigo Central causes of vertigo, on the other hand, stem from the central nervous system, particularly the brainstem and cerebellum, and include:
- Stroke or ischemia, which may present with vertigo lasting for minutes with nausea, vomiting, severe imbalance, and other neurological symptoms
- Vestibular migraine, which presents with attacks lasting hours but can also present with attacks lasting minutes or 24 hours, and is often accompanied by a migraine history and photophobia
- Multiple sclerosis, which can cause progressive fluctuating bilateral hearing loss that is steroid responsive, and may present with vision, skin, and joint problems
- Tumors affecting the brainstem or cerebellum, such as vestibular schwannoma, which may present with vertigo, chronic imbalance, and asymmetric hearing loss and tinnitus. Treatment depends on the specific cause, ranging from vestibular rehabilitation exercises for peripheral causes to medications like meclizine (25mg every 4-6 hours as needed) for symptomatic relief, and distinguishing between peripheral and central causes is crucial for appropriate management and to identify potentially serious conditions requiring urgent intervention, as emphasized in the clinical practice guideline for benign paroxysmal positional vertigo (update) 1.
From the Research
Peripheral Causes of Vertigo
- Vestibular neuritis
- Benign paroxysmal positional vertigo
- Ménière's disease 2
- Vestibular disorders, classified as acute, episodic, or chronic based on duration and symptom presentation 2
- Superior canal dehiscence syndrome
- Episodic ataxia type 2 3
Central Causes of Vertigo
- Cerebrovascular disorders related to the vertebrobasilar circulation
- Migraine
- Multiple sclerosis
- Tumors of the posterior fossa
- Neurodegenerative disorders
- Some drugs
- Psychiatric disorders 4
- Stroke
- Demyelinating diseases
- Posterior fossa tumors 2
- Cerebellar infarction 5
- Vertebrobasilar insufficiency 5
- Central lesions near the fourth ventricle 5
Differentiation Between Peripheral and Central Causes
- The patient's history, neurologic examination, and imaging studies are usually the key to differentiation of peripheral and central causes of vertigo 4
- Assessing nystagmus patterns, the vestibulo-ocular reflex, and the HINTS Plus test can help differentiate between peripheral and central causes of dizziness and vertigo 2
- The HINTS examination can help differentiate peripheral from central causes of dizziness and vertigo 6
- The duration of attacks is most helpful in distinguishing between central and peripheral causes; vertigo associated with vertebrobasilar insufficiency typically lasts minutes, whereas peripheral inner ear causes of recurrent vertigo typically last hours 5