Types of Vertigo and Their Treatments
Vertigo should be classified by timing and triggers rather than vague symptom descriptions, with the three main clinical syndromes being triggered episodic vestibular syndrome (primarily BPPV), spontaneous episodic vestibular syndrome (Ménière's disease, vestibular migraine), and acute vestibular syndrome (vestibular neuritis, labyrinthitis, or stroke). 1
Classification Framework
The modern approach to vertigo categorizes presentations based on temporal patterns and precipitating factors rather than symptom quality alone 2:
- Triggered Episodic Vestibular Syndrome: Vertigo episodes lasting seconds to minutes, provoked by specific head movements or position changes 1
- Spontaneous Episodic Vestibular Syndrome: Recurrent vertigo episodes lasting minutes to hours without specific triggers 1
- Acute Vestibular Syndrome: Continuous severe vertigo lasting days to weeks with acute onset 3, 1
Triggered Episodic Vestibular Syndrome
Benign Paroxysmal Positional Vertigo (BPPV)
BPPV is the most common cause of peripheral vertigo and should be treated with canalith repositioning procedures rather than medications. 4, 1
Clinical Features
- Brief episodes of vertigo (seconds to minutes) triggered by head position changes relative to gravity 4
- Accounts for the majority of triggered vertigo cases 1
- Two main variants exist based on canal involvement 4:
Diagnostic Approach
- Perform Dix-Hallpike maneuver for suspected posterior canal involvement 4, 5
- Perform supine roll test for lateral canal involvement 4, 5
- Both tests should be performed to avoid missing lateral canal BPPV 5
- No imaging is indicated for typical BPPV presentations 3
Treatment
- Canalith repositioning procedures (CRPs) are the primary treatment, with the specific maneuver chosen based on the affected canal 4
- Epley maneuver for posterior canal BPPV 6
- Lempert (barbecue roll) maneuver for lateral canal BPPV 6
- Semont maneuver as an alternative repositioning technique 6
- Vestibular suppressant medications should NOT be used for BPPV as they do not address the underlying pathophysiology 3
- Approximately 20% of cases resolve spontaneously by 1 month, 50% by 3 months 4
Other Triggered Causes
- Superior canal dehiscence syndrome: Triggered by pressure changes or Valsalva maneuver 1
- Perilymph fistula: Triggered by pressure changes 1
Spontaneous Episodic Vestibular Syndrome
Ménière's Disease
Ménière's disease presents with recurrent vertigo episodes lasting hours, accompanied by fluctuating hearing loss, tinnitus, and aural fullness, and should be treated with dietary sodium restriction and diuretics. 7, 8
Clinical Features
- Vertigo episodes typically lasting hours 9
- Associated with unilateral fluctuating sensorineural hearing loss 8
- Tinnitus and aural fullness in the affected ear 8
Treatment
- Low-salt diet (primary intervention) 7
- Diuretics in combination with dietary restriction 7
- Vestibular suppressants for acute symptom relief only 7
- Transtympanic corticosteroid or gentamicin injections for refractory cases 2
- Surgical ablative therapy reserved for patients with nonusable hearing who fail medical management 2
Vestibular Migraine
Vestibular migraine accounts for up to 14% of vertigo cases and presents with episodes lasting 5 minutes to 72 hours, with at least one migraine symptom during at least 50% of episodes. 1
Clinical Features
- Vertigo episodes lasting 5 minutes to 72 hours 1
- Migraine symptoms (headache, photophobia, phonophobia, visual aura) present during at least 50% of episodes 1
- May be triggered by typical migraine triggers including strong scents 1
Treatment
- Dietary modifications to avoid triggers 7
- Tricyclic antidepressants for prophylaxis 7
- Beta blockers or calcium channel blockers for prevention 7
Acute Vestibular Syndrome
In acute vestibular syndrome, approximately 25% of cases are due to cerebellar or brainstem stroke rather than peripheral vestibular disease, making stroke exclusion the critical first step. 3
Vestibular Neuritis
Vestibular neuritis presents with acute continuous vertigo lasting days without hearing loss and should be treated with oral corticosteroids within 3 days of onset. 3
Clinical Features
- Acute onset of severe, continuous rotatory vertigo lasting days to weeks 3
- Severe nausea, vomiting, and intolerance to head motion 3
- No hearing loss (key differentiator from labyrinthitis) 3
- Normal neurologic examination 3
Diagnostic Approach
- Comprehensive audiologic examination to confirm absence of hearing loss 3
- Immediate MRI indicated if: severe postural instability, direction-changing nystagmus, purely vertical nystagmus, additional neurologic symptoms, or high vascular risk factors 3
- No imaging needed for typical presentation with normal neurologic exam and no red flags 3
Treatment
- Methylprednisolone 100mg daily for 3 days, then taper over 7-10 days (must be initiated within 3 days of onset) 3
- Vestibular suppressants (meclizine 25-100mg daily in divided doses) for symptom control 10
- Vestibular suppressants must be discontinued after 3 days maximum to avoid impeding central compensation 3
- Antiemetics for nausea control, used sparingly 3
- Vestibular rehabilitation exercises after acute phase 7, 2
Labyrinthitis
Labyrinthitis is clinically identical to vestibular neuritis except for the presence of sensorineural hearing loss on the affected side. 3
Clinical Features
- Acute continuous vertigo lasting days to weeks 3
- Sensorineural hearing loss on affected side (key differentiator from vestibular neuritis) 3
- Severe nausea and vomiting 3
Treatment
- Same as vestibular neuritis: corticosteroids within 3 days, limited vestibular suppressants, vestibular rehabilitation 3
Critical Red Flags: Central Causes
Direction-changing nystagmus, purely vertical nystagmus, or downbeat nystagmus without torsional component strongly suggests central pathology requiring immediate neuroimaging. 3, 5, 9
Warning Signs Requiring Immediate MRI
- Severe postural instability or inability to walk 3
- Direction-changing nystagmus that doesn't follow typical BPPV patterns 3, 5
- Purely vertical nystagmus (upbeating or downbeating) 5, 9
- Downbeat nystagmus without torsional component 5
- Cerebellar signs: ataxia, dysmetria, dysdiadochokinesia 5
- Additional neurologic symptoms or focal deficits 3
- High vascular risk factors in appropriate clinical context 3
Cerebellar Stroke
- Can masquerade as peripheral vestibular lesion with vertigo and severe imbalance as only presenting features 9
- Approximately 25% of acute vestibular syndrome cases are stroke 3
- MRI is the preferred imaging modality; CT may not adequately visualize posterior fossa structures 5
Pharmacotherapy Considerations
Vestibular Suppressants
- Meclizine 25-100mg daily in divided doses is FDA-approved for vertigo associated with vestibular system diseases 10
- Should be used sparingly and for short duration only 3
- Maximum 3 days use to avoid impeding central vestibular compensation 3
- Causes drowsiness; caution with driving and operating machinery 10
- Anticholinergic effects: use with caution in asthma, glaucoma, or prostatic enlargement 10
Other Symptomatic Medications
- Diazepam 10mg IM once or twice daily to decrease internuclear inhibition in acute phase 6
- Antiemetics (metoclopramide 10mg IM, levo-sulpiride 50mg IV) for neurovegetative symptoms 6
- Gabapentin 300mg PO 2-3 times daily to reduce nystagmus and stabilize visual field 6
Common Pitfalls to Avoid
- Misdiagnosing central positional nystagmus as BPPV when proper diagnostic maneuvers are not performed or central features are overlooked 5
- Failing to perform both Dix-Hallpike and supine roll testing, missing lateral canal BPPV 5
- Using vestibular suppressants for BPPV instead of canalith repositioning procedures 3
- Prolonged use of vestibular suppressants beyond 3 days, impeding central compensation 3
- Missing cerebellar stroke in patients presenting with acute vestibular syndrome 3, 9
- Relying on CT imaging for posterior fossa evaluation instead of MRI 5