How to differentiate and manage vertigo versus other forms of dizziness in a patient?

Differentiating Vertigo from Other Forms of Dizziness

The critical first step is to determine whether the patient is experiencing true vertigo (a false sensation of self-motion or spinning) versus non-vertiginous dizziness (lightheadedness, presyncope, or disequilibrium), as this distinction fundamentally changes the diagnostic approach and urgency of evaluation. 1

Initial Symptom Characterization

Ask patients to describe their sensation without using the word "dizzy":

• True vertigo: Patient reports spinning, rotation, or that the room is moving around them—this indicates vestibular system pathology 1
• Lightheadedness: Sensation of impending faint or "floating"—suggests cardiovascular or metabolic causes 1
• Disequilibrium: Unsteadiness or imbalance without spinning—suggests proprioceptive, cerebellar, or multisensory deficits 2, 3
• Presyncope: Near-fainting sensation—indicates cardiovascular insufficiency 4, 3

Critical caveat: Elderly patients with long-standing vestibular disease may describe "vague dizziness" rather than frank spinning, but still have true vestibular pathology 1

Timing and Trigger-Based Classification for Vertigo

Once true vertigo is confirmed, classify by timing and triggers rather than descriptive terms—this is more reliable than patient descriptors: 1, 5

Triggered Episodic Vestibular Syndrome (episodes <1 minute, position-triggered):

• BPPV (most common, 42% of vertigo cases): Brief episodes triggered by specific head position changes 1, 5
• Postural hypotension: Triggered by standing 1
• Superior canal dehiscence: Triggered by loud sounds or Valsalva 1, 5
• Perilymph fistula: Triggered by pressure changes, may follow trauma 1

Spontaneous Episodic Vestibular Syndrome (minutes to hours, no trigger):

• Ménière's disease (10% of cases): Episodes lasting hours with fluctuating hearing loss, tinnitus, aural fullness 1, 5
• Vestibular migraine (3.2% of cases): Episodes lasting hours, migraine history, photophobia 1, 5
• Vertebrobasilar TIA: Episodes typically <30 minutes, no hearing loss, may precede stroke 1, 5

Acute Vestibular Syndrome (continuous days to weeks):

• Vestibular neuritis (41% of cases): Severe continuous vertigo lasting 12-36 hours, then gradual improvement over days, NO hearing loss 1, 5
• Labyrinthitis: Similar to vestibular neuritis but WITH hearing loss 1, 5
• Posterior circulation stroke: Continuous vertigo with neurologic signs 1, 5

Chronic Vestibular Syndrome (weeks to months):

• Anxiety/panic disorder 1, 5
• Medication side effects 1, 5
• Vestibular schwannoma: Chronic imbalance more than episodic vertigo 1

Peripheral vs. Central Vertigo Differentiation

This distinction is critical because central causes require urgent neuroimaging and may be life-threatening:

Nystagmus Characteristics (most reliable physical finding):

Peripheral vertigo nystagmus: 6, 5

• Horizontal with rotatory/torsional component
• Unidirectional (beats in same direction regardless of gaze)
• Suppressed by visual fixation
• Fatigable with repeated testing
• Brief latency (5-20 seconds) before onset

Central vertigo nystagmus: 6, 5

• Pure vertical (upbeating or downbeating) WITHOUT torsional component
• Direction-changing with gaze or without head position changes
• NOT suppressed by visual fixation
• Does NOT fatigue with repeated testing
• Baseline nystagmus present without provocative maneuvers

Associated Symptoms:

Peripheral vertigo: 1, 7

• Hearing loss, tinnitus, aural fullness
• Severe nausea/vomiting
• Patient can usually maintain some postural control

Central vertigo: 1, 6

• Dysarthria, dysmetria, dysphagia
• Diplopia, visual field defects
• Sensory or motor deficits
• Horner's syndrome
• Severe postural instability with inability to stand or walk (key distinguishing feature)

Dix-Hallpike Maneuver Interpretation:

Peripheral (BPPV): 6, 5

• 5-20 second latency before nystagmus onset
• Torsional and upbeating nystagmus
• Crescendo-decrescendo pattern
• Fatigable with repetition
• Resolves within 60 seconds

Central causes: 6, 5

• Immediate onset without latency
• Purely vertical nystagmus without torsional component
• Persistent, non-fatigable
• Downbeating nystagmus is particularly concerning

Red Flags Demanding Immediate Neuroimaging

Any of these findings indicate potential central pathology requiring urgent evaluation: 6, 5

• Severe postural instability with inability to stand/walk
• New-onset severe headache with vertigo
• Any focal neurologic symptoms (weakness, numbness, dysarthria, dysphagia, diplopia)
• Downbeating nystagmus on Dix-Hallpike without torsional component
• Baseline nystagmus without provocative maneuvers
• Gaze-evoked nystagmus
• Nystagmus that does NOT fatigue or suppress with visual fixation
• Limb weakness or hemiparesis
• Truncal/gait ataxia
• Failure to respond to appropriate peripheral vertigo treatments after 2-3 attempts

Critical statistic: 25% of patients with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 6

Management Algorithm

For Triggered Episodic Vertigo (<1 minute, position-triggered):

1. Perform Dix-Hallpike maneuver 1, 5
2. If positive with typical peripheral nystagmus: Diagnose BPPV, treat with Epley maneuver 1, 4
3. If atypical nystagmus or fails 2-3 repositioning attempts: Obtain MRI to exclude CNS pathology (3% have CNS disorders) 5

For Spontaneous Episodic Vertigo (minutes to hours):

1. Assess for hearing loss, tinnitus, aural fullness 1
   • If present with fluctuating hearing: Ménière's disease—treat with salt restriction and diuretics 1
2. Assess for migraine history, photophobia during episodes 1
   • If present: Vestibular migraine
3. If episodes <30 minutes without hearing loss in vascular risk patient: Consider vertebrobasilar TIA—urgent neurology referral 1, 5

For Acute Continuous Vertigo (days to weeks):

1. Assess for hearing loss 1
   • Without hearing loss: Vestibular neuritis—treat with vestibular rehabilitation 1, 4
   • With hearing loss: Labyrinthitis 1, 5
2. Perform HINTS examination if trained 5
3. If any red flags present: Immediate neuroimaging for stroke 6, 5

For Non-Vertiginous Dizziness:

• Lightheadedness/presyncope: Orthostatic vital signs, cardiac evaluation 4
• Disequilibrium: Neurologic examination, proprioceptive assessment 2, 3

Common Pitfalls to Avoid

• Overlooking subtle neurologic signs that indicate central pathology 6
• Misdiagnosing posterior circulation stroke as peripheral vestibular disorder (10% of cerebellar strokes present with isolated vertigo mimicking peripheral causes) 5, 8
• Failing to recognize vertebrobasilar insufficiency that may precede stroke by weeks to months 1, 5
• Not considering vestibular migraine in patients with both migraine and vertigo (commonly under-recognized) 6
• Assuming all positional vertigo is benign BPPV without performing proper Dix-Hallpike testing 5
• Ignoring medication side effects as cause of dizziness (antihypertensives, anticonvulsants, ototoxic drugs) 6
• Ordering routine neuroimaging for typical BPPV with characteristic nystagmus and no red flags (unnecessary and not recommended) 6, 5