HSV and Vertigo: Limited Direct Correlation with Important Caveats
There is no established direct correlation between chronic HSV-1 or HSV-2 infection and vertigo in the general population, but HSV-1 can cause acute vestibular neuritis and related vertigo syndromes through viral reactivation in the vestibular ganglia. 1, 2
Understanding the HSV-Vertigo Connection
The relationship between HSV and vertigo is not one of simple correlation but rather of specific pathophysiologic mechanisms:
HSV-1 and Vestibular Neuritis
HSV-1 reactivation in the vestibular ganglia is the suspected primary cause of vestibular neuritis, which presents as acute spontaneous vertigo with horizontal-torsional nystagmus, abnormal head impulse test, and unsteadiness. 1, 2
HSV-1 DNA has been detected in 62% of human vestibular ganglia and 48% of vestibular labyrinths in autopsy studies, indicating widespread latent infection that can potentially reactivate. 3
Vestibular neuritis preferentially involves the superior vestibular labyrinth, causing acute unilateral vestibular loss that manifests as severe vertigo lasting days. 1
Clinical Presentation When HSV Causes Vertigo
Acute vestibular syndrome from HSV-1 presents with prolonged continuous vertigo, nausea, vomiting, and imbalance rather than brief positional episodes. 2
One documented case showed HSV-1 vestibular neuronitis progressing to ipsilateral temporal lobe encephalitis within 3 days, demonstrating that isolated vertigo can be the initial presentation of more serious HSV-1 CNS disease. 4
In a study of 50 patients with labial HSV-1 outbreaks, 70% showed spontaneous nystagmus during active infection, suggesting subclinical vestibular involvement during viral reactivation, though most resolved within 7 days. 5
HSV-2 and Vertigo
HSV-2 showed no objective vestibular involvement in studied patients with active genital herpes, suggesting HSV-2 does not typically affect the vestibular system even during active outbreaks. 5
HSV-2 meningitis can present with headache, fever, and photophobia but vertigo is not a characteristic feature. 6, 7
Critical Red Flags Requiring Urgent Evaluation
When a patient with known HSV presents with vertigo, you must distinguish benign peripheral causes from life-threatening central pathology:
Negative head impulse test, direction-changing nystagmus, or skew deviation (HINTS examination) suggests central cause requiring immediate brain imaging. 8
Vertigo accompanied by fever, altered mental status, focal neurological deficits, or severe headache mandates MRI with diffusion-weighted imaging to exclude HSV encephalitis or stroke. 9, 8, 4
Unprecedented headache, severe unsteadiness, or lack of improvement within 1-2 days requires brain imaging even with typical vestibular neuritis features. 1
Management Approach
For Acute Vestibular Neuritis (Suspected HSV-1)
Oral corticosteroids within 3 days of symptom onset accelerate recovery of vestibular function in otherwise healthy individuals, though long-term benefit remains uncertain. 2
Antiemetics and vestibular suppressants should be used only during the first several days, as prolonged use impedes central vestibular compensation. 2
Early resumption of normal activity and directed vestibular rehabilitation therapy promote compensation and recovery. 2
When to Escalate to Antiviral Therapy
Intravenous acyclovir 10 mg/kg every 8 hours is indicated when vertigo is accompanied by signs of HSV meningitis or encephalitis (fever, photophobia, meningismus, altered mental status). 6, 7
Treatment duration is 14-21 days for HSV meningitis but must extend to 14-21 days for encephalitis due to high neurologic morbidity and mortality. 7
Oral antivirals (acyclovir, valacyclovir, famciclovir) are insufficient for CNS penetration and should not be used when central involvement is suspected. 6
Common Pitfalls to Avoid
Do not assume all vertigo in HSV-positive patients is HSV-related—benign paroxysmal positional vertigo (BPPV) is far more common and requires particle repositioning maneuvers, not antiviral therapy. 9
Do not miss posterior circulation stroke, which accounts for up to 11% of acute persistent vertigo cases and can mimic vestibular neuritis. 8
Do not delay imaging in patients with vascular risk factors—any patient with acute vestibular syndrome and stroke risk factors should be evaluated for possible brainstem or cerebellar infarction. 2
Benign paroxysmal positional vertigo may occur as a sequel to HSV-1 vestibular neuritis, possibly due to viral labyrinthitis causing otoconia displacement. 3
Bottom Line for Clinical Practice
Simply having HSV-1 or HSV-2 does not correlate with chronic or recurrent vertigo. However, HSV-1 reactivation can cause acute vestibular neuritis presenting as severe vertigo, and in rare cases can progress to life-threatening encephalitis. 4, 1 Your primary responsibility is distinguishing self-limited peripheral vestibular neuritis from central pathology requiring urgent intervention. 8, 1