What are the differential diagnoses and management options for a patient presenting with vertiginous dizziness?

Differential Diagnoses for Vertiginous Dizziness

The differential diagnosis of vertiginous dizziness is best approached by categorizing patients into four distinct temporal patterns based on timing and triggers rather than descriptive terms: triggered episodic vestibular syndrome (brief episodes <1 minute triggered by position changes), spontaneous episodic vestibular syndrome (episodes lasting minutes to hours without triggers), acute vestibular syndrome (continuous dizziness lasting days to weeks), and chronic vestibular syndrome (dizziness lasting weeks to months). 1, 2

Primary Classification by Timing and Triggers

Triggered Episodic Vestibular Syndrome (Brief, Position-Triggered)

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

• Benign Paroxysmal Positional Vertigo (BPPV) is the single most common cause, accounting for 42% of vertigo cases in primary care settings, characterized by brief spinning triggered by bending forward/backward, looking up, lying down, or rolling over in bed 1, 2, 3
• Postural hypotension presents with lightheadedness upon standing, confirmed by orthostatic vital signs 1
• Perilymphatic fistula causes positional vertigo, often with history of barotrauma or ear surgery 1, 2
• Superior canal dehiscence syndrome produces vertigo triggered by loud sounds or Valsalva maneuvers 1, 2
• Central paroxysmal positional vertigo mimics BPPV but shows atypical nystagmus patterns (purely vertical without torsional component, immediate onset without latency, non-fatigable) 1, 2

Spontaneous Episodic Vestibular Syndrome (Minutes to Hours, No Trigger)

Episodes lasting minutes to hours occurring spontaneously:

• Vestibular migraine is extremely common with 3.2% lifetime prevalence, accounting for up to 14% of all vertigo cases, characterized by episodes with photophobia, phonophobia, or visual aura during at least 50% of attacks 2, 4
• Ménière's disease presents with the classic triad: episodic vertigo lasting hours, fluctuating sensorineural hearing loss that worsens over time, tinnitus, and aural fullness 1, 2
• Posterior circulation transient ischemic attack (TIA) typically causes episodes lasting <30 minutes without hearing loss, may precede stroke by weeks or months, and shows gaze-evoked nystagmus and severe postural instability 1, 2
• Vertebrobasilar insufficiency presents similarly to TIA with isolated transient vertigo attacks 1, 2

Acute Vestibular Syndrome (Continuous Days to Weeks)

Acute persistent continuous dizziness with nausea, vomiting, and intolerance to head motion:

• Vestibular neuritis accounts for 41% of peripheral vertigo cases in non-specialty settings, presenting with severe vertigo lasting days without hearing loss 1, 2
• Labyrinthitis presents identically to vestibular neuritis but includes associated hearing loss 1, 2
• Posterior circulation stroke is critical to identify—approximately 25% of patients with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 2
• Demyelinating diseases (multiple sclerosis) can present with acute vertigo and central nystagmus patterns 1
• Posttraumatic vertigo follows head trauma with various manifestations including vertigo, disequilibrium, tinnitus, and headache 1, 2

Chronic Vestibular Syndrome (Weeks to Months)

Persistent dizziness lasting weeks to months:

• Anxiety or panic disorder causes chronic vague lightheadedness without true vertigo 1
• Medication side effects from ototoxic agents (aminoglycosides like gentamicin), anticonvulsants, antihypertensives, and cardiovascular medications 1, 2
• Posttraumatic vertigo can become chronic following head injury 1
• Posterior fossa mass lesions including vestibular schwannomas must be excluded 1, 2
• Cervicogenic vertigo presents with variable temporal patterns 1

Critical Distinction: Peripheral vs. Central Vertigo

Peripheral Vertigo Features

• Nystagmus characteristics: horizontal with rotatory component, unidirectional, suppressed by visual fixation, fatigable with repeated testing, brief latency period before onset 2
• Dix-Hallpike response: characteristic torsional and upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, fatigues with repeat testing, resolves within 60 seconds 2, 4
• Associated symptoms: hearing loss, tinnitus, aural fullness (Ménière's disease, labyrinthitis) 2
• Treatment response: responds to canalith repositioning procedures or vestibular rehabilitation 2

Central Vertigo Features (Red Flags Requiring Urgent Neuroimaging)

• Nystagmus characteristics: pure vertical (upbeating or downbeating) without torsional component, direction-changing without head position changes, direction-switching with gaze, not suppressed by visual fixation, baseline nystagmus without provocative maneuvers 2
• Severe postural instability with falling is the primary distinguishing feature of central causes, particularly vertebrobasilar insufficiency and cerebellar lesions 2
• Additional neurological symptoms: dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, Horner's syndrome, limb weakness, truncal/gait ataxia 2
• Downbeating nystagmus on Dix-Hallpike without torsional component is a critical red flag 2
• New-onset severe headache with vertigo may indicate vertebrobasilar stroke or hemorrhage 2
• Failure to respond to appropriate peripheral vertigo treatments demands neuroimaging 2
• Nystagmus that does not fatigue and is not suppressed by gaze fixation indicates central pathology 2

Management Algorithm

Step 1: Categorize by Timing and Triggers

Focus on precise timing (seconds vs. minutes vs. hours vs. days vs. weeks) and specific triggers (position changes vs. spontaneous) rather than patient's descriptive terms like "spinning" or "lightheadedness" 1, 2, 4

Step 2: Perform Targeted Physical Examination

• Dix-Hallpike maneuver is mandatory for all patients with brief episodic dizziness triggered by position changes to diagnose or exclude BPPV 2, 4, 3
• Supine roll test must also be performed to identify lateral canal BPPV, which accounts for up to 30% of BPPV cases 3
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners in acute vestibular syndrome 4
• Thorough neurologic exam including cranial nerve testing, cerebellar testing, gait assessment, and observation for spontaneous nystagmus 4
• Orthostatic blood pressure testing for suspected postural hypotension 1

Step 3: Assess for Red Flags

Immediate MRI brain (NOT CT) is required for: 2, 4

• Focal neurological deficits
• Severe postural instability with falling
• New-onset severe headache with vertigo
• Downbeating nystagmus without torsional component
• Baseline nystagmus without provocative maneuvers
• Sudden unilateral hearing loss
• Inability to stand or walk
• Failure to respond to appropriate peripheral vertigo treatments
• Apogeotropic horizontal nystagmus on supine roll test
• Progressive neurologic symptoms

CT head should NOT be used instead of MRI when stroke is suspected, as it has only 20-40% sensitivity for posterior circulation infarcts 4

Step 4: Diagnosis-Specific Treatment

For BPPV (most common cause):

• Canalith repositioning procedure (Epley maneuver) should be performed immediately if Dix-Hallpike is positive, with 80% success after 1-3 treatments and 90-98% after repeat maneuvers 2, 3
• Barbecue roll maneuver or Gufoni maneuver for lateral canal BPPV with 81-93% success rates 3
• Vestibular suppressants should NOT be prescribed for BPPV as they prevent central compensation 2

For vestibular migraine:

• Migraine prophylaxis and lifestyle modifications including dietary modifications 2, 4

For Ménière's disease:

• Dietary sodium restriction, diuretics, and vestibular rehabilitation 2

For vestibular neuritis:

• Vestibular rehabilitation therapy initiated as soon as possible 4
• Meclizine 25-100 mg daily in divided doses for symptomatic relief of vertigo associated with vestibular system diseases 5

For vertebrobasilar insufficiency/TIA:

• Urgent neurology consultation and stroke workup 2

Common Pitfalls to Avoid

• Overlooking vestibular migraine, which is extremely common but under-recognized, especially in young patients with both migraine and vertigo 2, 4
• Failing to distinguish fluctuating hearing loss (Ménière's disease) from stable/absent hearing loss (vestibular migraine) 2
• Skipping the Dix-Hallpike maneuver, the gold standard diagnostic test for BPPV 4
• Failing to perform both Dix-Hallpike AND supine roll testing, potentially missing lateral canal BPPV in up to 30% of cases 3
• Assuming normal neurologic exam excludes stroke, as 75-80% of posterior circulation strokes have no focal deficits 4
• Approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders, making red flag identification critical 2
• Ordering imaging for straightforward BPPV with typical nystagmus, which delays treatment unnecessarily 2, 4
• Relying on patient's description of "spinning" versus "lightheadedness" instead of focusing on timing and triggers 4
• Overlooking medication side effects as a cause, particularly ototoxic agents like aminoglycosides, which can cause irreversible vestibular toxicity 2
• Missing posttraumatic BPPV, which is more likely to be bilateral and require repeated treatments 2