What is the diagnosis and treatment for a patient with suspected vestibular syndrome, presenting with symptoms of dizziness, vertigo, and nausea?

Vestibular Syndrome: Diagnosis and Treatment

Vestibular syndrome requires immediate classification into one of four timing-based categories—acute, triggered episodic, spontaneous episodic, or chronic—to guide diagnosis and distinguish life-threatening central causes (particularly stroke) from benign peripheral disorders.

Initial Diagnostic Approach

The key to diagnosing vestibular syndrome is abandoning vague patient descriptions like "dizzy" or "lightheaded" and instead focusing on timing and triggers 1, 2. This approach categorizes patients into four distinct syndromes:

Four Clinical Categories

• Acute Vestibular Syndrome: Continuous vertigo lasting days to weeks with severe nausea, vomiting, and intolerance to head motion—includes vestibular neuritis, labyrinthitis, and posterior circulation stroke 1, 3
• Triggered Episodic Vestibular Syndrome: Brief episodes (<1 minute) triggered by specific head/body position changes—primarily BPPV 1, 2
• Spontaneous Episodic Vestibular Syndrome: Episodes lasting minutes to hours without positional triggers—includes vestibular migraine, Ménière's disease, and vertebrobasilar TIA 1
• Chronic Vestibular Syndrome: Dizziness lasting weeks to months—includes anxiety disorders, medication side effects, and posterior fossa masses 1, 2

Critical Distinction: Central vs. Peripheral Vertigo

Approximately 25% of patients with acute vestibular syndrome have stroke, not peripheral disease, making this distinction potentially life-saving 1, 3.

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, persistent without fatigue 1

Red Flags Demanding Immediate Neuroimaging

• Severe postural instability with falling 1, 2
• New-onset severe headache with vertigo 1, 2
• Any additional neurological symptoms (dysarthria, dysmetria, dysphagia, limb weakness, diplopia, Horner's syndrome) 1
• Downbeating nystagmus on Dix-Hallpike without torsional component 1
• Baseline nystagmus without provocative maneuvers 1
• Failure to respond to appropriate peripheral vertigo treatments 1

HINTS Examination for Acute Vestibular Syndrome

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) is MORE sensitive than early MRI for detecting posterior circulation stroke when performed by trained practitioners (100% sensitivity vs. 46% for MRI) 2. However, this examination is less reliable when performed by non-experts 2.

Specific Diagnoses and Treatment

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is the most common cause of peripheral vertigo, accounting for 42% of cases 1.

Diagnosis

• Episodes last seconds only (<1 minute), triggered by head position changes 4, 2
• Dix-Hallpike maneuver is the gold standard: Look for 5-20 second latency, torsional upbeating nystagmus toward affected ear, symptoms that crescendo then resolve within 60 seconds 4, 2
• No imaging or vestibular testing needed for typical BPPV with positive Dix-Hallpike 1, 2

Treatment

• Canalith repositioning procedures (Epley maneuver) are first-line treatment with 80% success after 1-3 treatments and 90-98% after repeat maneuvers 4, 2
• Medications are NOT indicated for typical BPPV other than short-term nausea relief 4, 2
• Reassess within one month to document resolution 2

Common Pitfall

• Atypical symptoms (hearing loss, gait disturbance, non-positional vertigo, persistent nausea/vomiting) after BPPV resolution warrant further evaluation for underlying CNS or vestibular disorders 4

Vestibular Neuritis and Labyrinthitis

The presence or absence of hearing loss is the key differentiator: labyrinthitis presents with hearing loss while vestibular neuritis does not 3.

Diagnosis

• Acute onset of severe, continuous rotatory vertigo lasting days to weeks 3
• Comprehensive audiologic examination required to distinguish between the two 3
• No imaging indicated if neurologic exam is normal and no red flags present 3

Treatment

• Oral corticosteroids within 3 days of onset (methylprednisolone 100mg daily for 3 days, then taper over 7-10 days) to accelerate recovery 3
• Symptomatic management with antiemetics 3
• Vestibular suppressants (e.g., meclizine) should be discontinued after 3 days maximum to avoid impeding central compensation 3, 5

Ménière's Disease

Diagnosis

• Classic triad: Episodic vertigo lasting hours, fluctuating sensorineural hearing loss, tinnitus, and aural fullness 1
• Accounts for 10% of vertigo cases in general practice, up to 43% in specialty settings 1

Treatment

• Dietary sodium restriction 1
• Diuretics 1
• Intratympanic treatments in refractory cases 2

Vestibular Migraine

Diagnosis

• Episodes can be short (<15 minutes) or prolonged (>24 hours) 1
• Visual auras commonly described before, during, or after attacks 1
• Motion intolerance and light sensitivity as triggers 1
• Key distinguishing feature from Ménière's: Hearing loss is mild, absent, or stable over time—NOT fluctuating 1

Treatment

• Migraine prophylaxis 2
• Lifestyle modifications 2

Vertebrobasilar Insufficiency (Central Cause)

Diagnosis

• Episodes typically last less than 30 minutes 1
• Isolated transient vertigo may precede stroke by weeks or months 1
• Severe postural instability 1
• Gaze-evoked nystagmus typical 1
• Nystagmus does NOT fatigue and is NOT suppressed by gaze fixation 1

Imaging Guidelines

Imaging has very low diagnostic yield in isolated dizziness 2:

• CT head detects causative pathology in <1% of cases and misses most posterior circulation infarcts 2
• MRI brain without contrast is superior (4% diagnostic yield vs. <1% for CT) and essential for detecting posterior circulation infarcts 2
• No imaging indicated for typical BPPV or peripheral vertigo with normal neurologic exam and no red flags 2
• MRI brain without contrast indicated for: high vascular risk patients with acute vestibular syndrome, abnormal neurologic examination, HINTS suggesting central cause, unilateral/pulsatile tinnitus, asymmetric hearing loss 2

Chronic Vestibular Syndrome

Common Causes

• Medication side effects (antihypertensives, sedatives, anticonvulsants, psychotropic drugs)—a leading reversible cause 2
• Anxiety, panic disorder, depression 2
• Posttraumatic vertigo 2
• Posterior fossa masses 1

Management

• Medication review is essential and often reveals reversible causes 2
• Psychiatric screening for anxiety and depression 2
• Vestibular rehabilitation therapy for persistent dizziness that fails initial treatment—significantly improves gait stability, particularly in elderly patients 2

Fall Risk Counseling

All patients with vestibular disorders are at greater risk for falls, particularly elderly and frail patients 4. Counseling should include:

• Home safety assessment 4
• Activity restrictions until symptoms resolve 4
• Need for home supervision between diagnosis and definitive treatment 4