What is the difference between dizziness and vertigo, and how are they managed?

Dizziness vs Vertigo: Key Distinctions and Management

Vertigo is a specific subtype of dizziness characterized by a false sensation of self-motion or spinning, while dizziness is a broader, non-specific term describing disturbed spatial orientation without a false sense of motion. 1, 2

Critical Definitions

Vertigo is defined as a false sensation of self-motion and a false sensation that the visual surroundings are spinning or flowing—this is the hallmark of inner ear or vestibular system dysfunction. 1

Dizziness encompasses a vague sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion, and may indicate lightheadedness, presyncope, or disequilibrium rather than true vestibular pathology. 1, 3

Diagnostic Approach: Focus on Timing and Triggers, Not Descriptors

The most critical diagnostic strategy is to abandon reliance on patient descriptors like "spinning" versus "lightheadedness" and instead focus on timing and triggers to categorize symptoms into four distinct vestibular syndromes. 1, 2, 3

The Four Vestibular Syndromes:

• Acute Vestibular Syndrome: Continuous dizziness lasting days to weeks with nausea, vomiting, and intolerance to head motion—includes vestibular neuritis, labyrinthitis, and posterior circulation stroke 1, 2

• Triggered Episodic Vestibular Syndrome: Brief episodes (<1 minute) triggered by specific head/body position changes—primarily BPPV and postural hypotension 1, 2

• Spontaneous Episodic Vestibular Syndrome: Episodes lasting minutes to hours without specific triggers—includes vestibular migraine, Ménière's disease, and vertebrobasilar TIA 1, 2

• Chronic Vestibular Syndrome: Dizziness lasting weeks to months—includes anxiety disorders, medication side effects, and posterior fossa masses 1, 2

Distinguishing Peripheral from Central Causes

Peripheral Vertigo Characteristics:

• Nystagmus: Horizontal with rotatory component, unidirectional, suppressed by visual fixation, fatigable with repeated testing, brief latency before onset 2

• Associated symptoms: Hearing loss, tinnitus, or aural fullness are common 1

• Dix-Hallpike response: Produces characteristic nystagmus with 5-20 second latency, crescendo-decrescendo pattern, resolves within 60 seconds 2, 3

• Postural stability: Patients can typically maintain some degree of balance 2

Central Vertigo Characteristics:

• Nystagmus: Pure vertical without torsional component, direction-changing without head position changes, not suppressed by visual fixation, does not fatigue 2

• Associated symptoms: Dysarthria, dysmetria, dysphagia, sensory/motor deficits, diplopia, or Horner's syndrome 2

• Severe postural instability: Patients cannot maintain balance and experience falling 2

• Dix-Hallpike response: Immediate onset, persistent nystagmus, purely vertical without torsional component 2

Common Peripheral Causes and Their Features

Benign Paroxysmal Positional Vertigo (BPPV):

• Brief episodes lasting seconds (<1 minute) triggered by head position changes 1
• No associated hearing loss, tinnitus, or aural fullness 1
• Most common cause of peripheral vertigo (42% of cases in general practice) 2

Ménière's Disease:

• Episodes lasting 20 minutes to 12 hours 1
• Fluctuating low-to-mid frequency hearing loss, tinnitus, and aural fullness in affected ear 1
• Spontaneous attacks of vertigo 1

Vestibular Neuritis:

• Acute prolonged vertigo lasting 12-36 hours with severe rotational component 1
• Decreasing disequilibrium over 4-5 days 1
• No hearing loss, tinnitus, or aural fullness 1

Labyrinthitis:

• Sudden severe vertigo with profound hearing loss 1
• Prolonged vertigo (>24 hours) 1
• Not episodic or fluctuating 1

Red Flags Requiring Urgent Evaluation

These findings mandate immediate neuroimaging (MRI preferred) and neurologic consultation: 2, 3

• Severe postural instability with falling 2
• New-onset severe headache with vertigo 2
• Any focal neurological symptoms (dysarthria, limb weakness, hemiparesis, truncal/gait ataxia) 2
• Downbeating nystagmus on Dix-Hallpike without torsional component 2
• Baseline nystagmus without provocative maneuvers 2
• Failure to respond to appropriate peripheral vertigo treatments 2
• Sudden hearing loss 3
• Inability to stand or walk 3

Critical pitfall: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits on standard examination—the HINTS examination is more sensitive than early MRI (100% vs 46% sensitivity) when performed by trained practitioners. 3

Management Strategies

BPPV Management:

• Canalith repositioning procedures (Epley maneuver) are first-line treatment 3
• No imaging or medication needed for typical cases 3
• Do not order neuroimaging or vestibular testing in patients meeting diagnostic criteria with positive Dix-Hallpike and no red flags 1, 3

Ménière's Disease Management:

• Salt restriction and diuretics 3
• Intratympanic dexamethasone or gentamicin for refractory cases 4

Vestibular Neuritis Management:

• Vestibular suppressant medications (meclizine is FDA-approved for vertigo associated with vestibular system diseases) 5
• Vestibular rehabilitation 6
• Steroids in acute phase 4

Vestibular Migraine Management:

• Migraine prophylaxis 3
• Lifestyle modifications 3
• Requires migraine symptoms during at least two vertiginous episodes for diagnosis 2

Imaging Decisions

No imaging is indicated for: 3

• Brief episodic vertigo with typical BPPV features
• Acute persistent vertigo with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner

MRI brain without contrast is indicated for: 3

• Acute persistent vertigo with abnormal neurologic examination
• HINTS examination suggesting central cause
• High vascular risk patients with acute vestibular syndrome
• Unilateral tinnitus, pulsatile tinnitus, or asymmetric hearing loss 3

Critical pitfall: CT head has very low diagnostic yield (<1%) for isolated dizziness and only 20-40% sensitivity for posterior circulation infarcts—MRI is vastly superior. 3

Common Clinical Pitfalls to Avoid

• Never rely solely on patient descriptors of "spinning" versus "lightheadedness"—focus on timing and triggers instead 2, 3

• Do not assume normal neurologic exam excludes stroke—most posterior circulation strokes present without focal deficits 3

• Avoid routine imaging for isolated dizziness—it has low yield and most findings are incidental 3

• Do not use CT instead of MRI when stroke is suspected—CT misses most posterior circulation infarcts 3

• Review medications systematically—they are a leading cause of chronic dizziness, particularly antihypertensives, sedatives, anticonvulsants, and psychotropic drugs 3

• Screen for psychiatric conditions—anxiety, panic disorder, and depression are common causes of chronic non-specific dizziness 3