What is peripheral vertigo?

What is Peripheral Vertigo

Peripheral vertigo is a false sensation of spinning or movement caused by disorders of the inner ear (vestibular system), characterized by brief, position-triggered episodes with specific nystagmus patterns that distinguish it from life-threatening central (brain) causes. 1

Anatomic Origin and Pathophysiology

Peripheral vertigo originates from dysfunction of the vestibular apparatus in the inner ear, including the semicircular canals, utricle, and vestibular nerve. 2 The most common mechanism involves calcium carbonate crystals (otoconia) becoming dislodged from their normal position in the utricle and floating into the semicircular canals, sending false signals to the brain about head movement. 3

Clinical Presentation

Cardinal Symptoms

• Rotational sensation: Patients experience a distinct feeling that they or their surroundings are spinning, triggered by specific head or body position changes. 3
• Episodic nature: Symptoms occur in sudden, brief spells rather than constant dizziness—typically lasting seconds to minutes for BPPV, or hours for Ménière's disease. 1, 4
• Position-dependent: Specific movements trigger episodes, such as rolling over in bed, looking up, bending over, or sitting up from lying down. 3
• Associated symptoms: Nausea (sometimes vomiting), sense of disorientation, and feeling unstable or losing balance are common during acute episodes. 3

What Peripheral Vertigo Does NOT Cause

• No constant severe dizziness unaffected by position or movement. 3, 4
• No hearing loss in most cases (except Ménière's disease and labyrinthitis). 3
• No loss of consciousness or fainting. 3, 4
• No neurological deficits such as weakness, numbness, speech problems, or vision changes. 1

Major Causes of Peripheral Vertigo

Benign Paroxysmal Positional Vertigo (BPPV)

• Most common cause, accounting for 42% of peripheral vertigo cases and representing the most frequent vestibular disorder across all age groups. 1, 4
• Episodes last less than 1 minute, triggered by specific head position changes. 1, 5
• Caused by displaced otoconia (calcium carbonate crystals) in the semicircular canals. 3, 5
• Posterior canal involvement occurs in 85-95% of BPPV cases. 4

Vestibular Neuritis

• Accounts for approximately 41% of peripheral vertigo cases in non-specialty settings. 1
• Presents with acute onset of severe vertigo lasting days to weeks. 1
• Inflammation of the vestibular nerve without hearing loss. 1

Ménière's Disease

• Accounts for 10% of vertigo cases in general practice, up to 43% in specialty settings. 1
• Episodic vertigo lasting hours with fluctuating hearing loss, tinnitus, and aural fullness. 1, 2
• Sustained vertigo attacks distinguish it from the brief episodes of BPPV. 1

Other Peripheral Causes

• Labyrinthitis: Inner ear inflammation causing vertigo with associated hearing loss. 1
• Superior Canal Dehiscence Syndrome: Abnormal opening in bone covering the superior semicircular canal, causing pressure-induced (not position-induced) vertigo. 1, 2
• Ototoxic medications: Particularly aminoglycosides like gentamicin, which can cause irreversible vestibular damage. 1
• Posttraumatic vertigo: Following head trauma with various manifestations. 1

Distinguishing Features from Central Vertigo

Nystagmus Characteristics (Critical Distinguishing Feature)

Peripheral vertigo nystagmus pattern:

• Horizontal with rotatory (torsional) component. 1
• Unidirectional (beats in same direction regardless of gaze). 1
• Suppressed by visual fixation. 1
• Fatigable with repeated testing. 1
• Brief latency period (delay) before onset after position change. 1

Central vertigo nystagmus pattern (red flags):

• Pure vertical (upbeating or downbeating) without torsional component. 1, 2
• Direction-changing without head position changes. 1, 2
• NOT suppressed by visual fixation. 1, 2
• Does not fatigue with repeated testing. 1, 2
• Baseline nystagmus present without provocative maneuvers. 1, 2

Associated Symptoms

• Peripheral vertigo: Isolated vertigo symptoms without neurological deficits. 1
• Central vertigo: Frequently accompanied by dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, or Horner's syndrome. 1

Response to Treatment

• Peripheral vertigo responds to canalith repositioning procedures (like Epley maneuver) or vestibular rehabilitation. 1, 2
• Central vertigo does NOT respond to these interventions—failure to respond is a red flag. 1, 2

Diagnostic Approach

Bedside Testing

• Dix-Hallpike maneuver: Produces characteristic nystagmus with latency and fatigability in peripheral causes (especially posterior canal BPPV). 3, 1, 5
• Supine roll test: Used to diagnose lateral canal BPPV. 3, 5
• Normal medical imaging (CT, MRI) and laboratory testing cannot confirm peripheral vestibular disorders—diagnosis is clinical. 3

Red Flags Requiring Urgent Evaluation for Central Causes

• Severe postural instability with falling. 1
• New-onset severe headache with vertigo. 1
• Any neurological symptoms (weakness, numbness, speech changes, vision problems). 1
• Downbeating nystagmus on Dix-Hallpike without torsional component. 1, 4
• Failure to respond to appropriate peripheral vertigo treatments. 1
• Baseline nystagmus without provocative maneuvers. 1

Clinical Pitfalls to Avoid

• Missing stroke: 10% of cerebellar strokes present similarly to peripheral vestibular disorders, and 25% of patients with acute vestibular syndrome have cerebrovascular disease. 1, 4
• Overlooking medication side effects: Many medications (anticonvulsants, antihypertensives, cardiovascular drugs) cause dizziness that mimics peripheral vertigo. 1, 2
• Ignoring fall risk: Patients with peripheral vertigo, especially elderly, have significantly increased fall risk—counsel about home safety and activity restrictions until resolved. 3
• Assuming single diagnosis: Multiple concurrent vestibular disorders can coexist (e.g., BPPV with Ménière's disease). 1

Treatment Considerations

• Meclizine is FDA-approved for treatment of vertigo associated with diseases affecting the vestibular system in adults. 6
• Canalith repositioning procedures (Epley maneuver for posterior canal BPPV, Gufoni maneuver for lateral canal BPPV) have approximately 80% success rates with only 1-3 treatments. 2, 5
• The natural course of BPPV is to become less severe over time, with many patients reporting their first episode was the worst. 3