What are the causes, diagnosis, and treatment options, including medications, for an adult patient with vertigo and no significant medical history?

Vertigo: Causes, Diagnosis, and Treatment

Causes of Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, accounting for 42% of cases, followed by vestibular neuritis (41%), Ménière's disease (10%), and vestibular migraine—but you must actively exclude stroke, which can mimic peripheral vertigo in 10% of cerebellar stroke cases. 1

Peripheral Causes (Vestibular System)

Most Common:

• BPPV: Brief episodes (<1 minute) triggered by head position changes, caused by mobile debris (canaliths) in the vestibular labyrinth 1
• Vestibular Neuritis: Acute onset severe vertigo lasting days to weeks, accounts for 41% of cases 1
• Ménière's Disease: Episodes lasting 20 minutes to 12 hours with fluctuating hearing loss, tinnitus, and aural fullness 1
• Vestibular Migraine: Lifetime prevalence 3.2%, accounts for up to 14% of vertigo cases, episodes last 5 minutes to 72 hours with photophobia, phonophobia, or visual aura 1, 2

Less Common:

• Labyrinthitis: Inflammation causing vertigo with associated hearing loss 1
• Posttraumatic Vertigo: Presents with vertigo, disequilibrium, tinnitus, and headache following head trauma 3, 1
• Superior Canal Dehiscence: Triggered by pressure changes (Valsalva maneuver) 2
• Perilymphatic Fistula: Pressure-triggered episodes with fluctuating hearing loss 2

Central Causes (Neurologic) - Critical to Exclude

Life-Threatening:

• Brainstem/Cerebellar Stroke: 10% of cerebellar strokes mimic peripheral vertigo; 75-80% have no focal neurologic deficits initially 1, 2
• Vertebrobasilar Insufficiency: Episodes <30 minutes, may precede stroke by weeks or months 1

Other Central Causes:

• Multiple Sclerosis: Demyelinating disease causing central vertigo 2
• Posterior Fossa Tumors: Including vestibular schwannomas 1
• Intracranial Masses: Require exclusion in chronic presentations 1

Other Causes

• Medication-Induced: Aminoglycosides (gentamicin), anticonvulsants (carbamazepine, phenytoin), antihypertensives, cardiovascular medications 3, 1
• Postural Hypotension: Triggered by moving from supine to upright position 3
• Anxiety/Panic Disorder: Can present as chronic vestibular syndrome 1
• Cervical Vertigo: Triggered by head rotation relative to body while upright 3

Diagnosis

Clinical Approach by Timing and Triggers

Focus on timing and triggers rather than descriptive terms to categorize vertigo into four syndromes: 1

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

   • BPPV (most common)
   • Postural hypotension 1

2. Spontaneous Episodic Vestibular Syndrome (minutes to hours, no triggers):

   • Vestibular migraine
   • Ménière's disease
   • Vertebrobasilar TIA 1

3. Acute Vestibular Syndrome (continuous days to weeks):

   • Vestibular neuritis
   • Labyrinthitis
   • Posterior circulation stroke 1

4. Chronic Vestibular Syndrome (weeks to months):

   • Anxiety disorders
   • Medication side effects
   • Posterior fossa masses 1

Physical Examination: Distinguishing Peripheral from Central

Nystagmus Characteristics:

Peripheral (BPPV/Vestibular Neuritis):

• Horizontal with rotatory/torsional component
• Unidirectional
• Suppressed by visual fixation
• Fatigable with repeated testing
• Brief latency (5-20 seconds) before onset 1

Central (Stroke/CNS):

• Pure vertical (upbeating or downbeating) without torsional component
• Direction-changing without head position changes
• Direction-switching with gaze
• NOT suppressed by visual fixation
• Immediate onset, persistent, non-fatigable 1

Dix-Hallpike Maneuver

Perform this maneuver to diagnose or exclude BPPV: 1

Positive for BPPV (Peripheral):

• Torsional and upbeating nystagmus
• 5-20 second latency
• Crescendo-decrescendo pattern
• Fatigues with repeat testing
• Resolves within 60 seconds 1

Concerning for Central Pathology:

• Immediate onset nystagmus
• Purely vertical without torsional component
• Persistent, non-fatiguing
• Downbeating nystagmus without torsional component 1

Red Flags Requiring Immediate Neuroimaging

Any of these findings demand urgent brain imaging (MRI preferred): 1

• Severe postural instability with falling
• New-onset severe headache with vertigo
• Any additional neurological symptoms (dysarthria, dysmetria, dysphagia, diplopia, Horner's syndrome, limb weakness, sensory deficits)
• Downbeating nystagmus on Dix-Hallpike without torsional component
• Baseline nystagmus without provocative maneuvers (though could indicate vestibular neuritis)
• Nystagmus that does NOT fatigue and is NOT suppressed by gaze fixation
• Gaze-evoked nystagmus
• Failure to respond to appropriate peripheral vertigo treatments
• Truncal/gait ataxia 1

When Additional Testing is Needed

Do NOT routinely order neuroimaging or vestibular testing in diagnosed BPPV without red flags. 1

Order additional testing when:

• Atypical clinical presentation
• Equivocal or unusual nystagmus findings on Dix-Hallpike
• Additional symptoms suggesting CNS or otologic disorder
• Multiple concurrent peripheral vestibular disorders suspected
• Abnormal Weber test (mandates formal hearing evaluation) 1

Specific Diagnostic Considerations

Ménière's Disease vs. Vestibular Migraine:

• Ménière's: Fluctuating hearing loss that worsens over time, tinnitus, aural fullness 1
• Vestibular Migraine: Stable or absent hearing loss, migraine features during ≥50% of episodes 1

Vertebrobasilar Insufficiency:

• Episodes <30 minutes without hearing loss
• Severe postural instability
• Nystagmus does NOT fatigue or suppress with gaze fixation
• May precede stroke by weeks or months 1

Treatment

BPPV (Most Common Cause)

Perform canalith repositioning procedure (Epley maneuver) immediately if Dix-Hallpike is positive. 1

• Do NOT prescribe vestibular suppressants for BPPV as they prevent central compensation 1
• Posttraumatic BPPV may require repeated treatments (up to 67% of cases vs. 14% for non-traumatic) 3
• Vestibular rehabilitation exercises if repositioning fails 1
• Failure to respond should raise concern for alternative diagnosis 3, 1

Vestibular Neuritis/Labyrinthitis

Initial Phase (Acute Symptoms):

• Position patient lying on healthy side with head and trunk raised 20 degrees 4
• Room should be quiet but not darkened 4

Pharmacotherapy for Symptom Control (Short-term only):

• Meclizine: 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 5
  • Common adverse reactions: drowsiness, dry mouth, headache, fatigue 5
  • Use caution with driving/operating machinery 5
  • Prescribe with care in asthma, glaucoma, or prostate enlargement 5
• Diazepam: 10 mg IM once or twice daily to decrease internuclear inhibition 4
• Antiemetics (for neurovegetative symptoms):
  • Metoclopramide 10 mg IM once or twice daily 4
  • Triethylperazine rectally once or twice daily 4

Vestibular Rehabilitation:

• Begin after acute phase resolves 6
• Can be self-administered or physical therapist-directed 7

Ménière's Disease

First-Line Treatment:

• Low-salt diet 1, 6
• Diuretics 1, 6
• Vestibular rehabilitation 1

Refractory Cases:

• Transtympanic corticosteroid or gentamicin injections 7
• Surgical ablative therapy reserved for patients with nonusable hearing who failed less definitive therapy 7

Vestibular Migraine

Treatment Approach:

• Dietary modifications and lifestyle interventions 1
• Tricyclic antidepressant 6
• Beta blocker or calcium channel blocker 6
• Requires ≥5 episodes of vestibular symptoms with current or history of migraine for diagnosis 2

Vertebrobasilar Insufficiency/Stroke

Immediate neuroimaging and neurology consultation required. 1

• 25% of patients with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 1

Anxiety-Related Vertigo

• Selective serotonin reuptake inhibitor (SSRI) 6

Critical Pitfalls to Avoid

Missing Stroke:

• 10% of cerebellar strokes present identically to peripheral vestibular disorders 1, 2
• 75-80% of stroke patients have NO focal neurologic deficits initially 1
• Isolated transient vertigo may precede vertebrobasilar stroke by weeks or months 1

Prescribing Vestibular Suppressants for BPPV:

• These medications prevent central compensation and should NOT be used for BPPV 1

Overlooking Multiple Concurrent Vestibular Disorders:

• BPPV can occur with Ménière's disease or vestibular neuritis 3, 1
• Consider this when clinical presentation is mixed 3

Failing to Distinguish Fluctuating vs. Stable Hearing Loss:

• Fluctuating hearing loss = Ménière's disease 1
• Stable/absent hearing loss = Vestibular migraine 1

Routine Neuroimaging in Typical BPPV:

• Imaging is unnecessary with typical nystagmus on Dix-Hallpike testing and no red flags 1

Medication Side Effects:

• Always review medication list, especially in older adults with polypharmacy 3, 1, 2
• Aminoglycosides can cause irreversible vestibular toxicity 1