Causes of Episodic Vertigo Attacks Lasting 24 Hours
Vertigo lasting 24 hours 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 life-threatening central causes from benign peripheral causes. 1, 2
Primary Diagnostic Framework
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 with nausea, vomiting, and intolerance to head motion. 3, 1 This duration immediately excludes BPPV (which lasts only seconds) and makes Ménière's disease unlikely, as definite Ménière's episodes last 20 minutes to 12 hours maximum, though "probable" Ménière's can extend to 24 hours. 1, 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, 2
- This is the most common peripheral cause of prolonged vertigo in this time frame. 1
Labyrinthitis
- Characterized by sudden severe vertigo with profound hearing loss and prolonged vertigo (>24 hours), distinguishing it from vestibular neuritis. 1, 2
- May present with severe otalgia and fever, with hearing losses often being permanent and not fluctuating. 1, 2
Cerebellar Stroke or Posterior Circulation Stroke
- May present with vertigo, nausea, vomiting, and severe imbalance, with insults being permanent and not fluctuating. 1, 2
- This is the most critical diagnosis to exclude due to its life-threatening nature and potential for intervention. 1
Algorithmic Approach to Differentiation
Step 1: Assess for Neurological Red Flags
The American Academy of Otolaryngology-Head and Neck Surgery mandates immediate emergency neuroimaging if any of the following are present: 1, 2
- Dysarthria or dysphagia
- Visual blurring or drop attacks
- Motor or sensory deficits
- Horner's syndrome
- Direction-changing nystagmus without head position changes
- Downbeating nystagmus
- Severe imbalance disproportionate to vertigo
Step 2: Assess for Hearing Loss
- Hearing loss present: Suggests labyrinthitis or less commonly otosyphilis. 1, 2
- No hearing loss: Suggests vestibular neuritis or cerebellar stroke. 1, 2
Step 3: Consider Vascular Risk Factors
- In patients with vascular risk factors (hypertension, diabetes, smoking, age >50), maintain high suspicion for posterior circulation stroke even without obvious neurological deficits. 2
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, 2
- Characterized by fluctuating hearing loss, aural fullness, and tinnitus in the affected ear, with hearing loss fluctuating rather than being permanent. 1
Vestibular Migraine
- Can cause attacks lasting hours, but 24 hours would be on the longer end of the spectrum. 1
- Presents with more photophobia than visual aura, and hearing loss is less likely than in Ménière's disease. 1
Posterior Circulation Transient Ischemic Attack
- Vertigo lasting minutes with severe imbalance, nausea, and vomiting without hearing loss suggests ischemia. 1
- However, posterior circulation ischemia very rarely causes isolated vertigo attacks lasting 24 hours; when it does, attacks are typically brief and frequent. 4
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, 2
- Do not dismiss neurological symptoms as anxiety when vertigo is accompanied by other symptoms. 1, 2
- Do not overlook subtle neurological signs in the presence of obvious vestibular symptoms; always check for dysarthria, dysphagia, and visual changes. 1, 2
- Do not delay imaging if vertigo persists >24 hours without improvement or if any central features are present. 5