What are the potential causes and treatment options for a patient presenting with vertigo?

Vertigo: Causes and Treatment

Classification by Timing and Triggers

Vertigo should be classified by timing and triggers rather than descriptive terms, as this approach more effectively distinguishes serious central causes from benign peripheral etiologies and guides management. 1, 2

The four key clinical syndromes are:

• Triggered episodic vestibular syndrome (t-EVS): Brief episodes (<1 minute) triggered by specific head/body position changes, most commonly BPPV or postural hypotension 1
• Spontaneous episodic vestibular syndrome: Episodes lasting minutes to hours without triggers, including vestibular migraine, Ménière's disease, and vertebrobasilar TIA 1
• Acute vestibular syndrome: Continuous dizziness lasting days to weeks with nausea, vomiting, and intolerance to head motion, including vestibular neuritis, labyrinthitis, and posterior circulation stroke 1
• Chronic vestibular syndrome: Dizziness lasting weeks to months, including anxiety disorders, medication side effects, and posterior fossa masses 1

Peripheral Causes (Most Common)

Benign Paroxysmal Positional Vertigo (BPPV)

• Accounts for 42% of vertigo cases in general practice settings 1
• Results from mobile debris (canaliths) in the vestibular labyrinth 3
• Characterized by brief episodes triggered by head position changes with typical nystagmus on Dix-Hallpike testing: torsional and upbeating with latency, crescendo-decrescendo pattern, resolution within 60 seconds 1, 2
• Imaging is unnecessary in BPPV with typical nystagmus on Dix-Hallpike testing 3

Vestibular Neuritis

• Accounts for approximately 41% of peripheral vertigo cases 1
• Presents with acute onset of severe vertigo lasting days to weeks 1

Ménière's Disease

• Accounts for 10% of vertigo cases in general practice, up to 43% in specialty settings 1
• Classic triad: episodic vertigo lasting hours, fluctuating sensorineural hearing loss that worsens over time, tinnitus, and aural fullness 1, 4
• The key distinguishing feature from vestibular migraine is fluctuating hearing loss 1

Other Peripheral Causes

• Labyrinthitis: inflammation causing vertigo with associated hearing loss 1
• Superior canal dehiscence syndrome 1
• Posttraumatic vertigo following head trauma 1
• Perilymphatic fistula 1
• Ototoxic medications, particularly aminoglycosides like gentamicin, can cause irreversible vestibular toxicity 1

Central Causes (Require Urgent Evaluation)

Vertebrobasilar Insufficiency

• Presents with isolated transient vertigo lasting less than 30 minutes without hearing loss 1, 4
• Can precede stroke by weeks to months 1, 4
• Characterized by severe postural instability, gaze-evoked nystagmus that does not fatigue, and nystagmus not suppressed by gaze fixation 1, 4

Stroke

• Brainstem and cerebellar stroke account for approximately 3% of vertigo cases in general practice 4
• 10% of cerebellar strokes can mimic peripheral vestibular disorders 1, 4
• Approximately 25% of patients with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 1

Vestibular Migraine

• Accounts for approximately 14% of all vertigo cases with lifetime prevalence of 3.2% 4
• Episodes can be short (<15 minutes) or prolonged (>24 hours) 1
• Diagnostic criteria require: episodic vestibular symptoms lasting 5 minutes to 72 hours, current or history of migraine, migraine symptoms during at least 50% of dizzy episodes 4
• Hearing loss is typically mild, absent, or stable over time—not fluctuating like Ménière's disease 1

Other Central Causes

• Multiple sclerosis and demyelinating diseases 4
• Posterior fossa tumors including vestibular schwannomas 1
• Medications: Mysoline, carbamazepine, phenytoin, antihypertensives, cardiovascular drugs 3, 4

Critical Red Flags Requiring Urgent Neuroimaging

The following findings mandate immediate imaging to exclude central pathology:

• Downbeating nystagmus on Dix-Hallpike without torsional component 1, 2, 4
• Direction-changing nystagmus without head position changes 1, 4
• Baseline nystagmus without provocative maneuvers 1, 4
• Nystagmus that does not fatigue with repeated testing and is not suppressed by visual fixation 1, 4
• Severe postural instability with falling 1, 4
• New-onset severe headache with vertigo 1
• Additional neurological symptoms: dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, Horner's syndrome 1, 4
• Failure to respond to appropriate peripheral vertigo treatments 1, 2
• Atypical Dix-Hallpike results or negative/atypical testing in patients with symptoms suggesting BPPV (central positional vertigo) 3, 2

Distinguishing Peripheral from Central Vertigo

Nystagmus Characteristics

Peripheral vertigo:

• Horizontal with rotatory component, unidirectional, suppressed by visual fixation, fatigable with repeated testing, brief latency before onset 1

Central vertigo:

• Pure vertical without torsional component, direction-changing without head position changes, not suppressed by visual fixation, immediate onset without latency 1

Clinical Examination

The Dix-Hallpike maneuver is essential for diagnosis:

• Peripheral (BPPV): characteristic nystagmus with latency, fatigability on repeat testing, torsional component 1, 2
• Central: immediate onset, persistent nystagmus, purely vertical without torsional component 1, 2

Treatment Approach

BPPV Management

Particle repositioning maneuvers (Epley maneuver) are the definitive treatment for BPPV, with 80-93% success rates after 1-3 treatments 2

• Vestibular suppressant medications should NOT be used as primary treatment due to significantly lower efficacy (30.8% vs 78.6-93.3% for repositioning maneuvers) 2
• Meclizine 25-100 mg daily may only be considered for severe nausea/vomiting during the maneuver itself or in patients who refuse repositioning, maximum 3-5 days 2, 5

Ménière's Disease Management

• First-line preventive therapy: dietary sodium restriction (1500-2300 mg daily) combined with diuretics 2
• Short-term vestibular suppressants (meclizine 25-100 mg daily in divided doses) for acute vertigo attacks 2, 5
• Limitation of alcohol and caffeine intake 2
• Betahistine may be considered to increase inner ear vasodilation 2

Vestibular Neuritis/Labyrinthitis

• Initial vestibular suppressant medications for symptom relief 2
• Followed by vestibular rehabilitation exercises 2

Vestibular Rehabilitation

• Indicated for persistent dizziness from any vestibular cause, chronic imbalance, or incomplete recovery 2
• Can be self-administered or therapist-directed 2

Critical Medication Warnings

Vestibular suppressants (meclizine) should be used with extreme caution:

• Significant adverse effects particularly in elderly: drowsiness, cognitive deficits, anticholinergic effects, increased fall risk 2, 5
• Contraindicated in patients with asthma, glaucoma, or prostate enlargement 2, 5
• Potential for drug interactions with CNS depressants and CYP2D6 inhibitors 5
• Patients must avoid driving and alcohol while taking these medications 5

Common Pitfalls to Avoid

• Overlooking subtle neurological signs that may indicate central pathology 1
• Misdiagnosing cerebellar stroke as peripheral vestibular disorder (occurs in 10% of cerebellar strokes) 1, 4
• Using vestibular suppressants as primary treatment for BPPV instead of repositioning maneuvers 2
• Failing to distinguish fluctuating hearing loss (Ménière's disease) from stable/absent hearing loss (vestibular migraine) 1
• Not recognizing that isolated transient vertigo may precede vertebrobasilar stroke by weeks to months 1, 4
• Overlooking medication side effects as a cause of vestibular symptoms 1

Follow-Up

Patients should be reassessed within 1 month after initial treatment to document resolution or persistence, and counseled on fall risk, potential recurrence, and importance of follow-up 2