What is the differential diagnosis and initial management for a patient presenting with vertigo?

Vertigo Differential Diagnosis and Initial Management

The differential diagnosis of vertigo is best organized by timing and triggers into four distinct clinical syndromes: triggered episodic (seconds to minutes, position-provoked), spontaneous episodic (minutes to hours, unprovoked), acute vestibular (days to weeks, continuous), and chronic vestibular (weeks to months), with each syndrome having its own specific differential diagnosis that guides immediate management decisions. 1

Algorithmic Approach by Timing and Triggers

Triggered Episodic Vestibular Syndrome (Brief, Position-Provoked)

Episodes lasting <1 minute triggered by specific head position changes:

• Benign Paroxysmal Positional Vertigo (BPPV) - Most common cause, accounting for 42% of vertigo cases in general practice 1, 2
• Postural hypotension - Provoked by moving from supine to upright position 1
• Perilymphatic fistula - Triggered by pressure changes (Valsalva), may have fluctuating hearing loss 1
• Superior canal dehiscence syndrome - Pressure-induced vertigo, not position-induced 1
• Vertebrobasilar insufficiency - Episodes typically <30 minutes, severe postural instability 1, 2
• Central paroxysmal positional vertigo - Red flag: purely vertical nystagmus without torsional component 1

Spontaneous Episodic Vestibular Syndrome (Unprovoked, Minutes to Hours)

• Vestibular migraine - Episodes lasting 5 minutes to 72 hours, migraine symptoms during ≥50% of episodes 2, 3
• Ménière's disease - Classic triad: episodic vertigo (hours duration), fluctuating hearing loss, tinnitus, and aural fullness 1, 2
• Posterior circulation TIA - Episodes <30 minutes, may precede stroke by weeks to months 1, 2
• Medication side effects - Anticonvulsants, antihypertensives, cardiovascular medications 1
• Anxiety or panic disorder - May mimic vestibular disorders, often with hyperventilation 1

Acute Vestibular Syndrome (Continuous, Days to Weeks)

• Vestibular neuritis - Acute severe vertigo without hearing loss, accounts for 41% of cases 1, 3
• Labyrinthitis - Similar to vestibular neuritis but with associated hearing loss 1
• Posterior circulation stroke - Critical: 25% of acute vestibular syndrome cases are stroke, rising to 75% in high vascular risk patients 2, 3
• Demyelinating diseases - Multiple sclerosis can present with isolated vertigo 1
• Posttraumatic vertigo - Following head trauma, may be bilateral and refractory 1

Chronic Vestibular Syndrome (Weeks to Months)

• Anxiety or panic disorder - Chronic dizziness with vestibular dysfunction 1
• Medication side effects - Ototoxic agents (aminoglycosides), chronic anticholinergics 1, 2
• Posttraumatic vertigo - Persistent symptoms after head injury 1
• Posterior fossa mass lesions - Tumors, vestibular schwannomas 2
• Cervicogenic vertigo - Associated with cervical spine disease, triggered by neck rotation relative to body 1

Critical Differentiation: Central vs. Peripheral Vertigo

Nystagmus Characteristics That Distinguish Central from Peripheral

Peripheral vertigo nystagmus:

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

Central vertigo nystagmus (RED FLAGS):

• Pure vertical without torsional component, direction-changing without head position changes, not suppressed by visual fixation, baseline nystagmus without provocation 2
• Downbeating nystagmus on Dix-Hallpike without torsional component demands immediate neuroimaging 2, 3

Associated Symptoms Indicating Central Pathology

Any of these neurological symptoms require urgent evaluation:

• Dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, Horner's syndrome 2
• Severe postural instability with falling (vertebrobasilar insufficiency, cerebellar lesions) 2, 3
• New-onset severe headache with vertigo (vertebrobasilar stroke or hemorrhage) 2
• Limb weakness, hemiparesis, truncal/gait ataxia 2

Dix-Hallpike Maneuver Interpretation

Peripheral (BPPV) pattern:

• Torsional and upbeating nystagmus with latency (1-5 seconds), crescendo-decrescendo pattern, fatigability on repeat testing, resolution within 60 seconds 2, 3

Central pattern (requires immediate MRI):

• Immediate onset without latency, persistent nystagmus without fatigability, purely vertical without torsional component 2, 3

Initial Management Algorithm

Step 1: Categorize by Timing and Triggers

• Ask specifically: Duration of episodes (seconds vs minutes vs hours vs days), triggers (position changes vs spontaneous), evolution over time 1

Step 2: Perform Targeted Physical Examination

For triggered episodic pattern:

• Dix-Hallpike maneuver for posterior canal BPPV 1, 3
• Supine roll test for lateral canal BPPV 1, 3
• If positive for BPPV: Treat immediately with canalith repositioning (Epley maneuver for posterior canal, Lempert barbecue roll for lateral canal) - 80% success rate 3

For acute vestibular syndrome:

• HINTS examination is essential to distinguish central from peripheral causes 4
• Check for direction-changing nystagmus, purely vertical nystagmus, severe postural instability 2, 3
• If any red flags present: Immediate MRI (not CT) for posterior fossa evaluation 3

Step 3: Red Flags Requiring Immediate Neuroimaging

Any of these mandate urgent MRI:

• Direction-changing nystagmus, purely vertical nystagmus, downbeat nystagmus without torsional component 2, 3
• Severe postural instability with falling, new-onset severe headache 2, 3
• Any additional neurological symptoms (dysarthria, diplopia, limb weakness, ataxia) 2
• Failure to respond to appropriate peripheral vertigo treatments 2
• Apogeotropic horizontal nystagmus on supine roll test, isolated positional downbeat nystagmus 2

Step 4: Specific Management Based on Diagnosis

BPPV (triggered episodic):

• Canalith repositioning procedures, NOT medications 3
• Epley maneuver for posterior canal (85-95% of cases), Lempert maneuver for lateral canal (5-15% of cases) 3
• Do NOT use vestibular suppressants - they don't address pathophysiology 3

Vestibular neuritis (acute vestibular syndrome without hearing loss):

• Oral corticosteroids within 3 days of onset 3
• Vestibular suppressants (meclizine 25-100mg daily) for maximum 3 days only to avoid impeding central compensation 3, 5
• Vestibular rehabilitation exercises after acute phase 3

Ménière's disease (spontaneous episodic with fluctuating hearing loss):

• Low-salt diet and diuretics 2, 6
• Vestibular rehabilitation 2

Vestibular migraine (spontaneous episodic with migraine features):

• Dietary modifications, tricyclic antidepressant, beta blocker or calcium channel blocker 6
• Distinguish from Ménière's by stable/absent hearing loss (not fluctuating) 2

Common Pitfalls to Avoid

Misdiagnosis of stroke as peripheral vertigo:

• 10% of cerebellar strokes present identically to peripheral vestibular disorders 2
• Always perform HINTS examination in acute vestibular syndrome 4
• Isolated transient vertigo may precede vertebrobasilar stroke by weeks to months 2

Overuse of vestibular suppressants:

• Meclizine should be used for maximum 3 days only 3
• Prolonged use impedes central vestibular compensation 3
• Never use for BPPV - repositioning procedures are the treatment 3

Overlooking concurrent diagnoses:

• BPPV can coexist with Ménière's disease or vestibular neuritis 1, 2
• Consider multiple vestibular disorders if presentation is mixed or atypical 1, 2

Failing to distinguish vestibular migraine from Ménière's disease:

• Key differentiator: fluctuating hearing loss that worsens over time (Ménière's) vs stable/absent hearing loss (vestibular migraine) 2
• Both can have episodic vertigo lasting hours 2

Routine neuroimaging without red flags:

• Do NOT order routine imaging for diagnosed BPPV without red flags 2
• MRI is indicated only for atypical presentations, equivocal Dix-Hallpike findings, or additional symptoms suggesting CNS/otologic disorder 2

Overlooking medication-induced vertigo:

• Ototoxic medications (aminoglycosides) can cause irreversible vestibular toxicity 2
• Anticonvulsants, antihypertensives, cardiovascular medications commonly cause dizziness 1