What are the possible causes of episodic vertigo attacks lasting 24 hours?

Episodic Vertigo Attacks Lasting 24 Hours: Differential Diagnosis

Vertigo lasting 24 hours or more is most commonly caused by vestibular neuritis, labyrinthitis, or cerebellar stroke, and the critical first step is determining whether neurological red flags are present to distinguish central (stroke) from peripheral (vestibular neuritis/labyrinthitis) causes. 1

Primary Diagnostic Framework

The duration of 24 hours immediately narrows your differential diagnosis significantly, as this excludes BPPV (which lasts only seconds) and makes Ménière's disease less likely (which typically lasts 20 minutes to 12 hours maximum, though "probable" Ménière's can extend to 24 hours). 2, 1 The American Academy of Otolaryngology-Head and Neck Surgery classifies vertigo lasting 24 hours as part of the "acute vestibular syndrome"—acute persistent continuous dizziness lasting days to weeks, usually associated with nausea, vomiting, and intolerance to head motion. 2

Most Common Causes

Vestibular Neuritis

• Presents with severe rotational vertigo lasting 12 to 36 hours with decreasing disequilibrium over the next 4-5 days, characterized by profound nausea and vomiting WITHOUT hearing loss, tinnitus, or aural fullness. 1
• This is the most common peripheral cause of prolonged vertigo in this time frame. 1, 3

Labyrinthitis

• Characterized by sudden severe vertigo with profound hearing loss and prolonged vertigo (>24 hours), distinguishing it from vestibular neuritis. 1, 4
• May present with severe otalgia and fever, and hearing losses are often permanent and do not fluctuate. 1
• The presence of hearing loss is the key distinguishing feature from vestibular neuritis. 1, 4

Cerebellar Stroke/Posterior Circulation Stroke

• May present with vertigo, nausea, vomiting, and severe imbalance; insults are permanent and do not fluctuate. 1
• This is the most critical diagnosis to exclude due to its life-threatening nature and potential for intervention. 5, 1

Critical Red Flags Requiring Emergency Neuroimaging

Any of the following mandate immediate imaging: 1

• Dysarthria or dysphagia 5, 1
• Visual blurring or drop attacks 5, 1
• Motor or sensory deficits 5, 1
• Horner's syndrome 1
• Direction-changing nystagmus without head position changes 5, 1
• Downbeating nystagmus 5, 1
• Severe imbalance disproportionate to vertigo 5, 1

Algorithmic Approach to Differentiation

Step 1: Assess for neurological red flags

• Perform targeted neurological examination for dysarthria, dysphagia, visual disturbances, motor/sensory deficits, or Horner's syndrome. 5
• If ANY red flags present → emergency neuroimaging to rule out stroke. 5, 1

Step 2: Assess for hearing loss

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

Step 3: Risk stratification for stroke

• Even without obvious neurological signs, do not assume all prolonged vertigo is benign vestibular neuritis without ruling out stroke, especially in patients with vascular risk factors (age >50, hypertension, diabetes, smoking, atrial fibrillation). 1

Less Common but Important Causes

Ménière's Disease (Atypical Presentation)

• Typically causes episodes lasting 20 minutes to 12 hours, but "probable" Ménière's can extend to 24 hours. 1
• Characterized by fluctuating hearing loss, aural fullness, and tinnitus in the affected ear. 2
• Unlike labyrinthitis, hearing loss in Ménière's fluctuates rather than being permanent. 1

Vestibular Migraine

• Can cause attacks lasting hours, but 24 hours would be on the longer end of the spectrum. 2
• More photophobia than visual aura, and hearing loss is less likely than in Ménière's disease. 5

Posterior Circulation Transient Ischemic Attack

• Listed as a cause of spontaneous episodic vestibular syndrome (lasting minutes to hours). 2
• Vertigo lasting minutes with severe imbalance, nausea, and vomiting without hearing loss suggests ischemia. 5

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. 1
• Do not dismiss neurological symptoms as anxiety when vertigo is accompanied by other symptoms. 5, 1
• Do not overlook subtle neurological signs in the presence of obvious vestibular symptoms; always check for dysarthria, dysphagia, and visual changes. 5
• Do not delay imaging if vertigo persists >24 hours without improvement or if any central features are present. 5
• Do not rely solely on neuroimaging in the acute setting, as early MRI can miss posterior circulation strokes. 1