What are the possible causes and treatment options for episodic vertigo attacks lasting 24 hours in a patient with unknown demographic and medical history?

Episodic Vertigo Attacks Lasting 24 Hours

Primary Diagnosis

Vertigo lasting 24 hours falls into the "acute vestibular syndrome" category, with vestibular neuritis being the most common peripheral cause, though posterior circulation stroke must be urgently excluded first. 1

The 24-hour duration immediately narrows your differential diagnosis significantly—this is too long for BPPV (which lasts <1 minute) and at the upper limit for Ménière's disease (typically 20 minutes to 12 hours). 1

Critical First Step: Exclude Stroke

Before considering benign causes, you must rule out posterior circulation stroke, which is life-threatening and potentially treatable. 1

Look for these red flags requiring emergency neuroimaging: 1, 2

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

A critical pitfall: 75-80% of patients with posterior circulation infarct have NO focal neurologic deficits, so a normal neurologic exam does not exclude stroke. 3

Most Likely Causes

Vestibular Neuritis (Most Common)

This is the most common peripheral cause of prolonged vertigo in this timeframe. 1

Characteristic features: 1

• Severe rotational vertigo lasting 12-36 hours
• Profound nausea and vomiting
• No hearing loss, tinnitus, or aural fullness (key distinguishing feature)
• Decreasing disequilibrium over the next 4-5 days

Labyrinthitis

Distinguished from vestibular neuritis by: 1

• Sudden severe vertigo with profound hearing loss
• Prolonged vertigo (>24 hours)
• May have severe otalgia and fever
• Hearing loss is typically permanent, not fluctuating

Posterior Circulation Stroke

This is the most critical diagnosis to exclude due to its life-threatening nature. 1

Features: 1

• Vertigo with nausea, vomiting, and severe imbalance
• Insults are permanent and non-fluctuating
• May have subtle or absent focal neurologic signs initially

Less Common Causes

Ménière's Disease (Atypical Duration)

Typically causes episodes lasting 20 minutes to 12 hours, but "probable" Ménière's can extend to 24 hours. 1

Key features: 4, 1

• Fluctuating hearing loss (not permanent)
• Aural fullness
• Tinnitus in the affected ear
• Hearing loss fluctuates rather than being permanent

Vestibular Migraine (Upper End of Spectrum)

24 hours would be on the longer end for vestibular migraine. 1

Features: 1

• More photophobia than visual aura
• Hearing loss less likely than in Ménière's disease
• Attacks typically last hours, not a full day

Posterior Circulation TIA

Listed as a cause of spontaneous episodic vestibular syndrome. 1

Features: 1

• Vertigo lasting minutes with severe imbalance
• Nausea and vomiting
• No hearing loss suggests ischemia

Diagnostic Algorithm

Step 1: Assess for neurological red flags 1

• Perform targeted neurological examination for dysarthria, dysphagia, visual disturbances, motor/sensory deficits, or Horner's syndrome
• Check for abnormal nystagmus patterns (direction-changing, downbeating)

Step 2: If ANY red flags present → Emergency neuroimaging (MRI preferred) 1, 3

• MRI brain without contrast is superior to CT (4% diagnostic yield vs <1% for CT)
• CT misses most posterior circulation infarcts

Step 3: If high vascular risk (age >50, hypertension, diabetes, prior stroke) → MRI even with normal exam 3

• 11-25% of high-risk patients may have posterior circulation stroke despite normal neurologic examination

Step 4: Assess for hearing loss 1

• Hearing loss present → Labyrinthitis or less commonly otosyphilis
• Hearing loss absent → Vestibular neuritis or cerebellar stroke

Step 5: If peripheral features confirmed and no red flags → Diagnose vestibular neuritis 1

Treatment Considerations

Acute Symptomatic Management

For acute vestibular neuritis or labyrinthitis: 5

• Antiemetics for neurovegetative symptoms (metoclopramide 10 mg IM once or twice daily)
• Vestibular suppressants only in acute phase (diazepam 10 mg IM)
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases 6

Positioning During Acute Phase

5

• Patient should lie on healthy side with head and trunk raised 20 degrees
• Room should be quiet but not darkened

Vestibular Rehabilitation

For persistent symptoms beyond initial treatment, vestibular rehabilitation therapy is the primary intervention. 1

• Significantly improves gait stability compared to medication alone
• Particularly beneficial for elderly patients or those with heightened fall risk

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 rely solely on neurologic examination to exclude stroke—most posterior circulation strokes present without focal deficits initially. 3

Do not dismiss neurological symptoms as anxiety when vertigo is accompanied by other symptoms. 1

Do not use CT instead of MRI when stroke is suspected—CT misses many posterior circulation infarcts. 3