What is the approach to diagnose vertigo?

Diagnostic Approach to Vertigo

The diagnosis of vertigo requires first confirming true vertigo (illusion of spinning or rotational movement), then distinguishing peripheral from central causes through targeted history and physical examination, with the Dix-Hallpike maneuver being essential for diagnosing the most common cause—benign paroxysmal positional vertigo (BPPV). 1

Step 1: Confirm True Vertigo vs. Other Dizziness

• Ask patients to describe the sensation specifically: True vertigo is a false sensation of self-motion or spinning of visual surroundings, not vague "dizziness," lightheadedness, or presyncope 1, 2
• Patients using vague terms like "dizziness" may be describing presyncopal episodes, which are not vertigo and require different evaluation 1
• Critical distinction: Loss of consciousness never occurs with vertigo and suggests a different diagnosis 1

Step 2: Classify by Timing and Triggers

Timing Categories 2

• Triggered episodic: Brief episodes (seconds to minutes) provoked by head position changes—suggests BPPV 1
• Spontaneous episodic: Attacks lasting minutes to hours without positional triggers—suggests Ménière's disease or vestibular migraine 1
• Acute vestibular syndrome: Continuous vertigo lasting hours to days—suggests vestibular neuritis or stroke 1, 3

Key Historical Features 1

• Onset: Spontaneous vs. provoked by head position relative to gravity
• Duration: Seconds (BPPV), minutes to hours (Ménière's, migraine), or days (neuritis, stroke)
• Associated otologic symptoms: Fluctuating hearing loss, tinnitus, or aural fullness occurring just before, during, or after attacks suggests Ménière's disease 1
• Provoking activities: Rolling over in bed, looking upward, or bending forward strongly suggests BPPV 1

Step 3: Distinguish Peripheral from Central Causes

Physical Examination for Nystagmus Characteristics

Peripheral vertigo nystagmus 3:

• Horizontal with rotatory (torsional) component
• Unidirectional (beats in same direction regardless of gaze)
• Suppressed by visual fixation
• Fatigable with repeated testing
• Brief latency period (5-20 seconds) before onset

Central vertigo nystagmus 4, 3:

• Pure vertical without torsional component
• Direction-changing without head position changes
• Direction-switching with gaze (beats right with right gaze, left with left gaze)
• NOT suppressed by visual fixation
• Baseline nystagmus present without provocative maneuvers

Red Flags for Central Causes 4, 3

• Neurological symptoms: Dysarthria, dysmetria, dysphagia, diplopia, sensory/motor deficits, Horner's syndrome, severe headache 1, 4
• Downbeating nystagmus on Dix-Hallpike without torsional component 4, 3
• Nystagmus of changing direction without head position changes 4
• Abnormal cranial nerve findings or visual disturbances 1
• Failure to respond to canalith repositioning after 2-3 attempts 4

Step 4: Perform Dix-Hallpike Maneuver for BPPV Diagnosis

Technique 1

Bring patient from upright to supine position with head turned 45 degrees to one side and neck extended 20 degrees

Diagnostic Criteria for Posterior Canal BPPV 1

• History: Repeated episodes of vertigo with head position changes
• Positive test: Vertigo with nystagmus provoked by maneuver
• Latency period: 5-20 seconds (up to 60 seconds) between maneuver completion and symptom onset
• Time-limited: Vertigo and nystagmus increase then resolve within 60 seconds from onset

For Lateral Canal BPPV 1

Perform supine roll testing with direction-changing nystagmus (geotropic or apogeotropic) that is stronger on one side

Step 5: Determine Need for Additional Testing

When Testing is NOT Needed 1

• Routine neuroimaging: Not indicated when clinical criteria for BPPV are met, as it does not improve diagnostic accuracy and adds unnecessary cost 1
• Vestibular function testing: Not needed when BPPV diagnosis is clear by clinical criteria 1
• Audiometric testing: No recommendation for routine use in BPPV 1

When Testing IS Indicated 1, 4

• Brain MRI with and without contrast (evaluating posterior fossa): When central vertigo suspected based on red flags 4
• Vestibular function testing: When diagnosis unclear, patient remains symptomatic after treatment, or multiple concurrent peripheral disorders suspected 1
• Urgent neuroimaging: Inconclusive positional testing with neurological signs, or failed treatment suggesting CNS disorder (3% of failed BPPV cases) 1, 4

Common Differential Diagnoses

Peripheral Causes 1, 3

• BPPV: 42% of general practice vertigo cases—brief positional episodes 1, 3
• Vestibular neuritis: 41% of cases—acute severe vertigo lasting days without hearing loss 1, 3
• Ménière's disease: 10% of cases—episodic vertigo with fluctuating hearing loss, tinnitus, aural fullness 1, 3
• Labyrinthitis: Sudden severe vertigo with profound hearing loss lasting >24 hours 1

Central Causes 1, 4

• Vestibular migraine: 3.2% prevalence, up to 14% of vertigo cases—attacks lasting hours with migraine history 1, 4
• Stroke/TIA: Vertebrobasilar insufficiency or cerebellar stroke—may present with isolated vertigo in 10% of cerebellar strokes 1, 4, 3

Critical Pitfalls to Avoid

• Missing cerebellar stroke: 10% present similarly to peripheral vestibular disorders—always assess for neurological signs 4, 3
• Overlooking medication effects: Aminoglycosides and other ototoxic drugs cause vestibular toxicity 3
• Misinterpreting nystagmus: Pure vertical nystagmus without torsion is central until proven otherwise 4, 3
• Ignoring treatment failure: Lack of response to repositioning maneuvers after 2-3 attempts mandates evaluation for central pathology 4