How is the diagnosis of vertigo made?

Diagnosis of Vertigo

The diagnosis of vertigo is made through a systematic clinical approach that first confirms true vertigo (a false sensation of spinning or self-motion) through targeted history, then classifies the presentation by timing and triggers, followed by physical examination including the Dix-Hallpike maneuver for BPPV, with imaging and vestibular testing reserved only for atypical presentations or red flag features. 1

Step 1: Confirm True Vertigo

• Ask patients to describe their sensation specifically to distinguish true vertigo from vague "dizziness," lightheadedness, or presyncope 2, 1
• True vertigo is defined as a false sensation of self-motion or a false sensation that visual surroundings are spinning or flowing 2, 3
• Use clarifying questions such as "Do you feel like you or the room is spinning?" to help patients articulate their symptoms 3
• Loss of consciousness never occurs with vertigo and indicates a different diagnosis entirely 2, 1, 3

Step 2: Classify by Timing and Triggers

This classification is more diagnostically valuable than symptom quality alone and helps narrow the differential diagnosis 1, 4:

• Triggered episodic vertigo (seconds to <1 minute): Brief episodes provoked by head position changes suggest BPPV 2, 1
• Spontaneous episodic vertigo (minutes to hours): Attacks without positional triggers suggest Ménière's disease or vestibular migraine 2, 1
• Acute vestibular syndrome (hours to days): Continuous vertigo suggests vestibular neuritis or stroke 1, 4
• Chronic vestibular syndrome (weeks to months): Persistent symptoms may indicate medication effects, psychiatric causes, or central pathology 4

Step 3: Obtain Targeted History

Inquire about specific features that distinguish different causes 2, 1:

• Duration of active vertigo: Seconds (BPPV), minutes to hours (Ménière's disease, vestibular migraine), or days (vestibular neuritis, stroke) 2
• Onset characteristics: Spontaneous versus provoked by head position changes 2
• Associated otologic symptoms: Fluctuating hearing loss, tinnitus, or aural fullness occurring immediately before, during, or after vertigo attacks suggest Ménière's disease 2
• Neurologic symptoms: Dysphagia, dysphonia, visual blurring, drop attacks, diplopia, dysarthria, numbness, or weakness suggest central causes 2, 4
• Migraine history: Photophobia, phonophobia, or prior migraine diagnosis suggests vestibular migraine 2, 4
• Otalgia and fever: May indicate infectious causes like Lyme disease 2

Step 4: Perform Physical Examination

Dix-Hallpike Maneuver for BPPV Diagnosis

The Dix-Hallpike maneuver is the gold standard diagnostic test for posterior canal BPPV 2:

• Bring the patient from upright to supine position with head turned 45 degrees to one side and neck extended 20 degrees 2, 1
• If the first side is negative, repeat with the other ear down before concluding a negative test 2
• Diagnostic criteria for positive test: 2, 1
  • Vertigo associated with torsional (rotatory), upbeating nystagmus is provoked
  • Latency period of 5-20 seconds (rarely up to 1 minute) between maneuver completion and symptom onset
  • Provoked vertigo and nystagmus increase then resolve within 60 seconds from nystagmus onset

Nystagmus Characteristics

Distinguish peripheral from central causes by nystagmus pattern 1:

• Peripheral vertigo nystagmus: Horizontal with rotatory (torsional) component, unidirectional, suppressed by visual fixation, fatigable with repeated testing 1
• Central vertigo nystagmus: Pure vertical without torsional component, direction-changing without head position changes, not suppressed by visual fixation 1, 4
• Pure vertical nystagmus without torsion is central until proven otherwise 1

Neurologic Examination

• Complete cranial nerve examination, cerebellar testing (finger-to-nose, heel-to-shin), and gait assessment are essential 4
• Observe for spontaneous nystagmus, particularly central patterns 4
• Assess for skew deviation, central fixation nystagmus, gaze-evoked nystagmus, and saccadic smooth pursuit to differentiate peripheral from central lesions 5

Step 5: Determine Need for Additional Testing

When Testing is NOT Indicated

• Do not order routine neuroimaging when clinical criteria for BPPV are met, as it does not improve diagnostic accuracy and adds unnecessary cost and radiation exposure 2, 1
• Do not order vestibular function testing when BPPV diagnosis is clear by clinical criteria (history plus positive Dix-Hallpike), as comprehensive testing is unnecessary 2
• A diagnosis made by appropriate history and Dix-Hallpike maneuver is adequate to proceed with management without further testing 2

When Testing IS Indicated

Comprehensive vestibular testing may be warranted when 2:

• Clinical presentation is atypical
• Dix-Hallpike testing elicits equivocal or unusual nystagmus findings
• Diagnosis remains unclear
• Additional symptoms suggest accompanying CNS or otologic disorder
• Multiple concurrent peripheral vestibular disorders are suspected
• Patient remains symptomatic after appropriate treatment 1

Brain MRI with and without contrast is indicated when central vertigo is suspected based on red flags 1, 4:

• Focal neurological deficits
• Sudden unilateral hearing loss
• Inability to stand or walk
• Downbeating or other central nystagmus patterns
• New severe headache
• Progressive neurologic symptoms

Common Differential Diagnoses

Understanding the distinguishing features helps narrow the diagnosis 2, 1:

• BPPV (42% of cases): Brief positional episodes lasting seconds, no hearing loss, tinnitus, or aural fullness 2, 1
• Vestibular neuritis (41% of cases): Acute severe vertigo lasting days without hearing loss 2, 1
• Ménière's disease (10% of cases): Episodic vertigo with fluctuating hearing loss, tinnitus, and aural fullness 2, 1
• Vestibular migraine (3.2% of cases): Attacks lasting hours with migraine history, more photophobia than visual aura 2, 1
• Stroke/TIA: May present with isolated vertigo in 10% of cerebellar strokes; look for dysphagia, dysphonia, or other neurologic symptoms 2, 1
• Vestibular schwannoma: Chronic imbalance more likely than profound episodic vertigo; hearing loss does not fluctuate 2
• Labyrinthitis: Sudden severe vertigo with profound hearing loss lasting >24 hours, not episodic or fluctuating 2

Critical Pitfalls to Avoid

• Missing cerebellar stroke: 75-80% of posterior circulation strokes have no focal deficits on neurologic exam; always assess for neurological signs even when exam appears normal 1, 4
• Skipping the Dix-Hallpike maneuver: This is the gold standard diagnostic test for BPPV and should not be omitted 4
• Relying on CT head for suspected stroke: CT has limited sensitivity for posterior circulation stroke; use MRI when central pathology is suspected 4
• Misinterpreting nystagmus: Pure vertical nystagmus without torsion indicates central pathology 1
• Ignoring treatment failure: Lack of response to repositioning maneuvers after 2-3 attempts mandates evaluation for central pathology 1
• Ordering imaging for straightforward BPPV: This delays treatment unnecessarily when clinical criteria are met 4
• Overlooking medication effects: Aminoglycosides and other ototoxic drugs can cause vestibular toxicity 1