What is the approach to assessing vertigo, including definition, classification, differential diagnosis, history, physical examination, investigations, treatment, and referral indications?

Approach to Assessment of Vertigo

Definition

Vertigo is a sensation that you or the environment around you is moving or spinning, indicating dysfunction of the vestibule, semicircular canals, or central vestibular pathways. 1 This differs from non-specific dizziness, which may imply disequilibrium, light-headedness, or presyncope. 1

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Classification

By Timing and Triggers 1, 2, 3

• Triggered Episodic Vestibular Syndrome: Seconds to minutes of vertigo triggered by head movements (e.g., BPPV) 2
• Spontaneous Episodic Vestibular Syndrome: Minutes to hours of vertigo without specific triggers (e.g., Ménière's disease, vestibular migraine) 2
• Acute Vestibular Syndrome: Days to weeks of continuous severe vertigo with nausea, vomiting, and intolerance to head motion (e.g., vestibular neuritis, labyrinthitis, stroke) 4
• Chronic Vestibular Syndrome: Persistent symptoms lasting weeks to months, often multifactorial 2

By Anatomic Origin 1, 5

• Peripheral (Vestibular): Involving the inner ear structures (vestibule, semicircular canals, vestibular nerve) 1
• Central: Affecting brainstem, cerebellum, or central vestibular pathways 1

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Differential Diagnosis

Common Peripheral Causes 1, 5, 6

• Benign Paroxysmal Positional Vertigo (BPPV): Most common cause; brief episodes (<1 minute) triggered by head position changes 1, 2
• Vestibular Neuritis: Acute, continuous vertigo without hearing loss 4
• Labyrinthitis: Acute, continuous vertigo with hearing loss 4
• Ménière's Disease: Episodic vertigo with hearing loss, tinnitus, and aural fullness 1
• Superior Canal Dehiscence Syndrome: Sound-induced vertigo (Tullio phenomenon) 1
• Perilymphatic Fistula: Vertigo triggered by pressure changes 1

Central Causes 1, 7

• Posterior Circulation Stroke/TIA: Approximately 25% of acute vestibular syndrome cases 4
• Vestibular Migraine: Episodic vertigo with headache, photophobia, phonophobia 2
• Demyelinating Diseases (e.g., multiple sclerosis) 1
• Central Nervous System Lesions: Tumors, cerebellar pathology 1
• Vertebrobasilar Insufficiency 1

Other Entities 1, 2

• Medication Side Effects: Antihypertensives, sedatives, anticonvulsants, psychotropics 2
• Anxiety/Panic Disorder 1
• Postural Hypotension 1
• Posttraumatic Vertigo 1

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History

Character of Symptoms 2, 3

Focus on timing and triggers rather than vague descriptions of "dizziness." 2

• Duration: Seconds (BPPV), minutes to hours (Ménière's, vestibular migraine), days to weeks (vestibular neuritis, labyrinthitis, stroke) 2, 3
• Onset: Sudden vs gradual 6
• Triggers: Positional changes (BPPV), pressure changes (superior canal dehiscence), no trigger (vestibular neuritis) 2, 3
• Pattern: Episodic vs continuous 2

Associated Symptoms 2, 3

• Hearing loss, tinnitus, aural fullness: Suggests Ménière's disease or labyrinthitis 4, 2
• Headache, photophobia, phonophobia: Suggests vestibular migraine 2
• Nausea and vomiting: Common in acute vestibular syndrome 4
• Neurological symptoms: Diplopia, dysarthria, dysphagia, weakness, numbness suggest central cause 8, 6

Red Flags Requiring Urgent Evaluation 2, 3

• Focal neurological deficits 2
• Sudden hearing loss 2
• Inability to stand or walk 2
• New severe headache 2
• Downbeating nystagmus or other central nystagmus patterns 2
• Failure to respond to appropriate vestibular treatments 2

Risk Factors for Stroke 4, 2

• High vascular risk: Hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation, prior stroke/TIA 2
• Age >50 years 7

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Physical Examination (Focused)

Otologic Examination 3, 8

• External auditory canal and tympanic membrane inspection 3
• Hearing assessment (whisper test, Weber and Rinne tests) 8

Vestibular Examination 2, 3

• Dix-Hallpike Maneuver: Gold standard for posterior canal BPPV; positive if latency 5-20 seconds, torsional upbeating nystagmus toward affected ear, symptoms resolve within 60 seconds 2
• Supine Roll Test: For lateral canal BPPV; direction-changing horizontal nystagmus (geotropic or apogeotropic) 1

HINTS Examination (for Acute Vestibular Syndrome) 4, 2

HINTS (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, superior to early MRI (46% sensitivity). 2

• Head Impulse Test: Abnormal (corrective saccade) suggests peripheral; normal suggests central cause 2
• Nystagmus: Direction-changing or purely vertical nystagmus suggests central cause 4
• Test of Skew: Vertical misalignment suggests central cause 2

Neurological Examination 8, 6

• Cranial nerves: Especially eye movements for ophthalmoplegia and nystagmus 8
• Cerebellar testing: Finger-to-nose, heel-to-shin, rapid alternating movements 8
• Gait and posture assessment: Severe postural instability suggests central cause 4
• Romberg test 9

Cardiovascular Examination 8

• Orthostatic vital signs (if syncope suspected) 8

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Investigations

When Imaging is NOT Indicated 2

• Typical BPPV with positive Dix-Hallpike test and no red flags 2
• Acute vestibular syndrome with normal neurologic exam and HINTS consistent with peripheral vertigo by trained examiner 2
• Vestibular neuritis or labyrinthitis with normal neurologic exam and no red flags 4

When Imaging IS Indicated 2

MRI brain without contrast is the preferred imaging modality when indicated. 2

• Acute vestibular syndrome with abnormal neurologic examination 2
• HINTS examination suggesting central cause 2
• High vascular risk patients with acute vestibular syndrome 2
• Unilateral or pulsatile tinnitus 2
• Asymmetric hearing loss 2
• Progressive neurologic symptoms 2

Audiologic Testing 4, 2

• Comprehensive audiologic examination: To distinguish labyrinthitis (sensorineural hearing loss) from vestibular neuritis (normal hearing) 4
• Indicated for: Unilateral tinnitus, persistent symptoms, associated hearing difficulties 2

Laboratory Testing 3

• Basic metabolic panel, CBC, thyroid function: Only if dehydration, electrolyte abnormalities, infection, or thyroid disorder suspected 3

Expected Findings 1, 2

• BPPV: Positive Dix-Hallpike or supine roll test; no imaging abnormalities 2
• Vestibular Neuritis: Abnormal head impulse test; normal hearing; normal MRI 4
• Labyrinthitis: Abnormal head impulse test; sensorineural hearing loss on affected side; normal MRI 4
• Posterior Circulation Stroke: Abnormal HINTS; MRI with diffusion-weighted imaging shows infarct 2
• Superior Canal Dehiscence: CT temporal bone shows bony dehiscence 1

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Empiric Treatment

BPPV 2

Canalith repositioning procedures (Epley maneuver) are first-line treatment with 80% success after 1-3 treatments and 90-98% after repeat maneuvers. 2

• No medications needed for typical BPPV 2
• Reassess within one month 2

Vestibular Neuritis 4

Oral corticosteroids within 3 days of onset accelerate recovery of vestibular function. 4

• Methylprednisolone 100mg daily for 3 days, then taper over 7-10 days 4
• Vestibular suppressants (meclizine, dimenhydrinate): Use sparingly, discontinue after 3 days maximum to avoid impeding central compensation 4
• Antiemetics for symptomatic relief 4

Ménière's Disease 2

• Salt restriction and diuretics 2
• Intratympanic treatments in refractory cases 2

Vestibular Migraine 2

• Migraine prophylaxis and lifestyle modifications 2

Vestibular Rehabilitation Therapy 2

Primary intervention for persistent dizziness that has failed initial treatment; significantly improves gait stability compared to medication alone. 2

• Includes: Habituation exercises, gaze stabilization, balance retraining, fall prevention 2
• Particularly beneficial for: Elderly patients, those with CNS disorders, heightened fall risk 2

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Indications to Refer

Urgent Referral (Emergency Department/Neurology) 4, 2

• Suspected posterior circulation stroke: New severe headache, high vascular risk with acute vestibular syndrome, abnormal HINTS examination 4, 2
• Focal neurological deficits 2
• Inability to stand or walk 2
• Severe postural instability 4

ENT/Otolaryngology Referral 2

• Unilateral or pulsatile tinnitus 2
• Asymmetric hearing loss 2
• Failure to respond to appropriate vestibular treatments 2
• Suspected superior canal dehiscence or perilymphatic fistula 1
• Refractory Ménière's disease 2

Vestibular Rehabilitation Referral 2

• Persistent dizziness despite initial treatment 2
• Elderly patients with balance concerns 2
• Patients with CNS disorders or heightened fall risk 2

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Critical Pitfalls

Diagnostic Pitfalls 2

• Relying on patient's description of "spinning" vs "lightheadedness": Focus on timing and triggers instead 2
• Assuming normal neurologic exam excludes stroke: 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits 2
• Failing to perform Dix-Hallpike maneuver in patients with positional symptoms 3
• HINTS examination performed by non-experts is less reliable: Results should be interpreted with caution 2

Imaging Pitfalls 2

• Routine imaging for isolated dizziness has low yield: Most findings are incidental 2
• Using CT instead of MRI when stroke is suspected: CT misses many posterior circulation infarcts (sensitivity only 20-40%) 2
• Ordering neuroimaging for typical BPPV: Unnecessary and delays treatment 2

Treatment Pitfalls 4, 2

• Prolonged use of vestibular suppressants: Impedes central compensation; discontinue after 3 days maximum 4
• Ordering comprehensive vestibular testing for straightforward BPPV: Unnecessary and delays treatment 2
• Failing to treat BPPV with canalith repositioning procedures: Medications are ineffective 2

Management Pitfalls 2

• Not reassessing BPPV patients within one month: Important to document resolution or persistence 2
• Ignoring medication review in chronic dizziness: Leading reversible cause 2
• Failing to screen for psychiatric symptoms in chronic dizziness: Anxiety and depression are common causes 2