What are the causes of vertigo?

Causes of Vertigo

Vertigo arises from either peripheral vestibular disorders (most commonly benign paroxysmal positional vertigo, vestibular neuritis, and Ménière's disease) or central nervous system pathology (including stroke, vestibular migraine, and demyelinating diseases), with the distinction made primarily through timing, triggers, and associated symptoms. 1, 2

Peripheral Vestibular Causes

Benign Paroxysmal Positional Vertigo (BPPV)

• BPPV is the most common cause of peripheral vertigo, accounting for 42% of cases in general practice settings 2, 3
• Episodes last less than one minute (typically seconds) and are triggered by specific head position changes 1
• Caused by calcium carbonate crystals (otoconia) dislodging from their normal position and floating in the semicircular canals 4
• Not associated with hearing loss, tinnitus, or aural fullness 1
• Diagnosed through Dix-Hallpike maneuver, which produces characteristic nystagmus with latency, fatigability on repeat testing, and torsional component 2, 4

Vestibular Neuritis/Labyrinthitis

• Accounts for approximately 41% of peripheral vertigo cases in non-specialty settings 2
• Presents with sudden severe vertigo lasting more than 24 hours (typically 12-36 hours of severe rotational vertigo) with profound nausea and vomiting 1, 3
• Vestibular neuritis occurs without hearing loss, tinnitus, or aural fullness, while labyrinthitis includes sudden profound hearing loss 1
• Attributed to viral infection of the vestibular system 1, 3
• Decreasing disequilibrium continues for 4-5 days after the acute phase 1

Ménière's Disease

• Accounts for 10% of vertigo cases in general practice and up to 43% in specialty settings 2
• Characterized by spontaneous episodic vertigo lasting hours (not minutes or seconds) with fluctuating hearing loss, tinnitus, and aural fullness occurring immediately before, during, or after attacks 1, 2
• Vertigo attacks are spontaneous rather than positionally triggered 1, 3
• Hearing loss and tinnitus fluctuate over time, distinguishing it from permanent losses seen in other conditions 1

Other Peripheral Causes

• Superior Canal Dehiscence Syndrome: Abnormal opening in bone covering the superior semicircular canal, causing pressure-induced (not position-induced) vertigo 2, 3, 4
• Perilymphatic Fistula: Abnormal connection between middle and inner ear causing triggered episodic vertigo 1, 3
• Posttraumatic Vertigo: Various manifestations including vertigo, disequilibrium, tinnitus, and headache following head trauma; trauma can also trigger BPPV 2, 3

Central Nervous System Causes

Stroke/Vertebrobasilar Insufficiency

• Vertigo may last minutes with nausea, vomiting, and severe imbalance, often accompanied by visual blurring and drop attacks 1, 3
• Isolated transient vertigo may precede stroke in the vertebrobasilar artery by weeks or months 2, 3
• Attacks typically last less than 30 minutes without associated hearing loss 2
• Approximately 25% of patients presenting with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 2
• Insults are permanent and do not fluctuate; may include dysphagia, dysphonia, or other neurologic symptoms but usually no hearing loss or tinnitus 1

Vestibular Migraine

• Presents with attacks lasting hours but can also present with attacks lasting minutes or more than 24 hours 1, 3
• Patients often have migraine history with more photophobia than visual aura 1, 3
• Hearing loss is less likely than in Ménière's disease 1
• Timing of attacks may be shorter or longer than Ménière's disease 1

Other Central Causes

• Demyelinating Diseases (Multiple Sclerosis): May present with progressive fluctuating bilateral hearing loss alongside vertigo and vision problems 3
• Vestibular Schwannoma: Presents with chronic imbalance and asymmetric hearing loss more commonly than profound episodic vertigo; hearing loss does not typically fluctuate 1
• Central Nervous System Lesions: Brainstem or cerebellar lesions can cause vertigo 3

Infectious and Inflammatory Causes

• Viral or bacterial infections (including Lyme disease, adenovirus, staph/strep) can lead to complete hearing loss and vestibular crisis with prolonged vertigo 1, 3
• Losses are often permanent and do not fluctuate; can present with severe otalgia and fever 1
• Otosyphilis: Sudden unilateral or bilateral sensorineural fluctuating hearing loss, tinnitus, and/or vertigo, though vertigo attacks not typically associated with aural symptoms immediately before or after 1

Other Causes

Medication-Induced

• Ototoxic medications, particularly aminoglycosides like gentamicin, can cause irreversible vestibular toxicity with dizziness, vertigo, tinnitus, and hearing loss 2
• Anticonvulsants, antihypertensives, and cardiovascular medications can also cause vertigo 2, 3, 4

Miscellaneous

• Postural Hypotension: Episodic dizziness when moving from supine to upright position 1, 3, 4
• Cervical Vertigo: Associated with degenerative cervical spine disease, triggered by head rotation relative to body while upright 3, 4
• Psychological Disorders: Panic disorder, anxiety disorder, or agoraphobia may present with lightheadedness and dizziness mimicking vertigo 3, 4
• Autoimmune Disorders: Can cause progressive fluctuating bilateral hearing loss with vertigo, may present with vision, skin, and joint problems 3

Critical Distinguishing Features for Diagnosis

Timing and Triggers

• Brief episodes (<1 minute) triggered by head position changes: BPPV 1, 2
• Spontaneous episodes lasting hours: Ménière's disease or vestibular migraine 1, 2
• Acute continuous vertigo lasting days to weeks: Vestibular neuritis, labyrinthitis, or posterior circulation stroke 1, 2
• Episodes lasting less than 30 minutes without hearing loss: Vertebrobasilar insufficiency 2

Nystagmus Characteristics

• Peripheral vertigo nystagmus: Horizontal with rotatory component, unidirectional, suppressed by visual fixation, fatigable with repeated testing, brief latency before onset 2
• Central vertigo nystagmus: Pure vertical without torsional component, direction-changing without head position changes, not suppressed by visual fixation, persistent without modification on repositioning 2

Red Flags for Central Pathology Requiring Urgent Neuroimaging

• Severe postural instability with falling 2, 3
• New-onset severe headache with vertigo 2
• Any additional neurological symptoms (dysarthria, dysmetria, dysphagia, sensory/motor deficits, diplopia, Horner's syndrome) 2
• Downbeating nystagmus on Dix-Hallpike without torsional component 2
• Baseline nystagmus without provocative maneuvers 2
• Nystagmus that does not fatigue and is not suppressed by gaze fixation 2
• Failure to respond to appropriate peripheral vertigo treatments 2