What are vestibular symptoms?

Vestibular Symptoms: Clinical Manifestations

Vestibular symptoms encompass four core manifestations: vertigo/dizziness (perceptual), nystagmus (ocular motor), ataxia (postural), and nausea (autonomic), which arise from dysfunction of the vestibular system and its central nervous system connections. 1

Core Symptom Categories

Perceptual Symptoms

• Vertigo is the primary perceptual symptom, characterized by a rotational or spinning sensation that can be triggered by head position changes or occur spontaneously 2
• Dizziness represents a broader category of spatial disorientation, ranging from lightheadedness to severe disorientation in space 2, 1
• Spatial disorientation manifests as a severe sense of disorientation during acute episodes 2
• Residual dizziness presents as lingering feelings of instability at a lesser level after acute episodes resolve 2

Ocular Motor Symptoms

• Nystagmus is the involuntary rhythmic eye movement that accompanies vestibular dysfunction, with characteristics (direction, duration, fatigability) helping differentiate peripheral from central causes 1, 3
• Oscillopsia occurs when patients perceive visual motion or bouncing of the environment, typically from bilateral vestibular loss or central vestibular pathology 1

Postural Symptoms

• Ataxia manifests as impaired balance and coordination, with gait disturbance being a common presentation 1, 2
• Instability can occur as isolated symptom, particularly in older adults who may not experience classic vertigo 2
• Postural imbalance presents as to-and-fro sensation with difficulty maintaining upright posture 1

Autonomic Symptoms

• Nausea is the predominant autonomic manifestation, often accompanied by vomiting during acute episodes 1, 4
• These symptoms are typically worsened with head movement 4

Clinical Classification by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery emphasizes that timing (acute vs episodic vs chronic) and triggers (discrete vs spontaneous) are more important than the specific descriptor patients use 5

Acute Vestibular Syndrome

• Sudden-onset, continuous vertigo lasting days to weeks with associated nausea, vomiting, and intolerance to head motion 5, 4
• Common causes include vestibular neuritis, labyrinthitis, and posterior circulation stroke 5

Triggered Episodic Vestibular Syndrome

• Brief episodes (typically <1 minute) triggered by specific head or body position changes 5
• Characterized by latency period of 5-20 seconds between position change and symptom onset 2
• Classic presentation of BPPV with episodes lasting 10-60 seconds 2

Spontaneous Episodic Vestibular Syndrome

• Episodes lasting minutes to hours without specific triggers 5
• Includes vestibular migraine (episodes 5 minutes to 72 hours) and Ménière's disease 5

Chronic Vestibular Syndrome

• Persistent symptoms lasting weeks to months or longer 5
• May result from anxiety/panic disorders, medication side effects, or posterior fossa lesions 5

Associated Symptoms by Etiology

Peripheral Vestibular Disorders

• Hearing loss, aural fullness, and tinnitus suggest Ménière's disease when occurring with episodic vertigo 5
• Pressure-induced vertigo (triggered by Valsalva) indicates superior canal dehiscence syndrome rather than position-induced symptoms 5, 3
• Conductive hearing loss may accompany superior canal dehiscence due to altered bone-conducted thresholds 5, 3

Central Vestibular Disorders

• Neurological symptoms including dysarthria, dysmetria, dysphagia, or sensory/motor loss suggest brainstem or cerebellar involvement 5, 2
• Horner's syndrome may accompany posterior circulation stroke 5
• Headache with photophobia, phonophobia, or visual aura suggests vestibular migraine 5

Red Flag Symptoms

The following atypical symptoms warrant further evaluation for underlying vestibular or CNS disorders: 2

• Subjective hearing loss (not typical of BPPV) 2
• Gait disturbance unrelated to positional changes 2
• Non-positional vertigo occurring without head position changes 2
• Persistent nausea and vomiting not resolving with positional changes 2
• Constant severe dizziness unaffected by position or movement 2
• Fainting episodes 2

Behavioral and Psychiatric Manifestations

• Anxiety-related vestibular symptoms affect 30-50% of patients consulting for vestibular complaints 6
• Fear of falling is a significant motivating factor for seeking evaluation, particularly in older adults 2
• Symptom avoidance is common, with patients modifying movements to prevent triggering episodes 2
• Psychiatric disorders (anxiety, traumatic stress, obsessive, depressive) may be primary causes or secondary complications of vestibular disorders 6

Clinical Pitfalls

• Failure to respond to appropriate repositioning treatments requires diagnostic reassessment, as this suggests the underlying diagnosis may not be peripheral vestibular pathology 5, 2
• Direction-changing nystagmus without head position changes, downbeating nystagmus without torsional component, or baseline nystagmus without provocative maneuvers strongly suggest central rather than peripheral causes 5, 3
• The first episode of vestibular symptoms is typically most severe, with subsequent episodes being less intense 2