What are the causes of vertigo attacks lasting 24 hours or more?

Causes of Vertigo Attacks Lasting 24 Hours

Vertigo lasting 24 hours or more is most commonly caused by vestibular neuritis, labyrinthitis, or cerebellar stroke, with the critical distinction being whether neurological red flags are present to indicate a central (stroke) versus peripheral (vestibular neuritis/labyrinthitis) cause. 1, 2

Primary Diagnostic Framework

The duration of 24 hours or more immediately narrows your differential diagnosis significantly, as this excludes most common causes of vertigo:

• Benign paroxysmal positional vertigo (BPPV) lasts only seconds and can be excluded 1
• Ménière's disease causes episodes lasting 20 minutes to 12 hours (definite) or up to 24 hours (probable), but not beyond 1
• Vertebrobasilar ischemia/TIA typically causes vertigo lasting only minutes 1, 3
• Vestibular migraine usually lasts hours but can extend beyond 24 hours, though this is less common 1

Most Common Causes of Prolonged Vertigo (≥24 Hours)

Vestibular Neuritis

• Presents with severe rotational vertigo lasting 12 to 36 hours with decreasing disequilibrium over the next 4-5 days 1
• Characterized by profound nausea and vomiting without hearing loss, tinnitus, or aural fullness 1, 2
• Caused by viral infection of the vestibular system 1
• This is the most common benign cause of acute vestibular syndrome 2

Labyrinthitis

• Sudden severe vertigo with profound hearing loss and prolonged vertigo (>24 hours) 1
• Unlike vestibular neuritis, this includes hearing loss as a distinguishing feature 1
• Viral or bacterial infection can lead to complete hearing loss and vestibular crisis 1
• May present with severe otalgia and fever, and losses are often permanent and do not fluctuate 1

Cerebellar Stroke/Infarction

• The most critical diagnosis not to miss because it can lead to cerebellar herniation and death 2
• May present with vertigo, nausea, vomiting, and severe imbalance 1
• Cerebellar infarction can masquerade as a peripheral vestibular lesion because vertigo and severe imbalance may be the only presenting features 3
• Insults are permanent and do not fluctuate 1

Algorithmic Approach to Differentiation

Step 1: Screen for Stroke Red Flags (MUST DO FIRST)

Any of the following require emergency neuroimaging: 4, 5

• Dysarthria or dysphagia (speech or swallowing difficulties) 1, 4
• Visual blurring or drop attacks 1, 4
• Motor or sensory deficits (limb weakness or numbness) 4, 5
• Horner's syndrome (pupillary changes, ptosis, anhidrosis) 4
• Direction-changing nystagmus without head position changes 4, 5
• Downbeating nystagmus 4, 5
• Severe imbalance disproportionate to vertigo (inability to stand or walk) 4, 5

Step 2: Assess for Hearing Loss

• Hearing loss present = labyrinthitis or less commonly otosyphilis 1
• No hearing loss = vestibular neuritis or cerebellar stroke 1, 2

Step 3: Perform HINTS Plus Examination

The HINTS Plus examination (Head Impulse test, Nystagmus, Test of Skew, Plus hearing loss) is more sensitive and specific than early neuroimaging for detecting stroke in acute vestibular syndrome 2:

• Abnormal head impulse test (normal corrective saccade) suggests central cause 2
• Direction-changing or vertical nystagmus suggests central cause 4, 2
• Vertical skew deviation suggests central cause 2
• Hearing loss suggests labyrinthitis (peripheral) 2

Step 4: Consider Less Common Causes

Autoimmune conditions (e.g., multiple sclerosis):

• Progressive fluctuating bilateral hearing loss that is steroid-responsive 1
• May present with vision, skin, and joint problems 1

Otosyphilis:

• Sudden unilateral or bilateral sensorineural fluctuating hearing loss, tinnitus, and/or vertigo 1
• Vertigo attacks not typically associated with aural symptoms immediately before or after attacks 1

Vestibular migraine (extended duration):

• Can present with attacks lasting more than 24 hours, though less common 1
• Patients often have migraine history with more photophobia than visual aura 1
• Hearing loss is less likely than in Ménière's disease 1

Critical Pitfalls to Avoid

• Do not assume all prolonged vertigo is benign vestibular neuritis without ruling out stroke, especially in patients with vascular risk factors 4, 2
• Do not rely solely on neuroimaging in the acute setting, as early MRI can miss posterior circulation strokes; clinical examination (HINTS Plus) is more sensitive 2
• Do not dismiss neurological symptoms as anxiety when vertigo is accompanied by other symptoms 4, 5
• Do not overlook subtle neurological signs in the presence of obvious vestibular symptoms 4
• MRI is indicated in any patient with acute vertigo and profound imbalance suspected to be the result of cerebellar infarct or hemorrhage 3