What conditions can cause vertigo in patients?

Conditions That Cause Vertigo

Vertigo arises from either peripheral vestibular disorders (most commonly benign paroxysmal positional vertigo, vestibular neuritis, and Ménière's disease) or central neurologic causes (stroke, migraine, multiple sclerosis, tumors), with the critical imperative being immediate identification of life-threatening central causes that require urgent neuroimaging. 1, 2, 3

Peripheral Vestibular Causes

Most Common Peripheral Disorders

• Benign Paroxysmal Positional Vertigo (BPPV) is the single most common cause of vertigo, accounting for 42% of cases in general practice settings 2

  • Episodes last less than 1 minute (typically seconds), triggered by specific head position changes 1, 2
  • No associated hearing loss, tinnitus, or aural fullness 1
  • Results from mobile debris (canaliths) in the vestibular labyrinth 2
  • Affects 9% of elderly patients referred to geriatric clinics, with three-fourths having fallen within the preceding 3 months 3

• Vestibular Neuritis accounts for approximately 41% of peripheral vertigo cases in non-specialty settings 2

  • Acute onset of severe rotational vertigo lasting 12 to 36 hours with decreasing disequilibrium for 4-5 days 1
  • Prolonged nausea and vomiting without hearing loss, tinnitus, or aural fullness 1
  • Viral infection of the vestibular system 1

• Ménière's Disease accounts for 10% of vertigo cases in general practice and up to 43% in specialty settings 2

  • Episodes last 20 minutes to 12 hours 1, 3
  • Classic triad: fluctuating sensorineural hearing loss (low- to mid-frequency), tinnitus, and aural fullness in the affected ear 1, 2
  • Hearing loss worsens and fluctuates over time—this is the key distinguishing feature 2

Other Peripheral Causes

• Labyrinthitis presents with sudden severe vertigo lasting more than 24 hours with profound hearing loss 1

  • Not episodic or fluctuating—losses are often permanent 1
  • May present with severe otalgia and fever if infectious etiology 1

• Vestibular Migraine has a lifetime prevalence of 3.2% and accounts for up to 14% of all vertigo cases 2, 3

  • Episodes last 5 minutes to 72 hours (can be shorter than 15 minutes or longer than 24 hours) 2
  • Requires ≥5 episodes of vestibular symptoms with current or history of migraine 3
  • Hearing loss is typically mild, absent, or stable over time—not fluctuating like Ménière's disease 2
  • Motion intolerance, photophobia, and phonophobia are common triggers 2

• Superior Canal Dehiscence Syndrome involves an abnormal opening in the bone covering the superior semicircular canal 2

  • Pressure-related triggers (e.g., Valsalva maneuver) differentiate it from BPPV 3

• Perilymphatic Fistula is an abnormal connection between the middle and inner ear 2

  • Can occur post-surgery or spontaneously with pressure-triggered episodes and fluctuating hearing loss 3

• Posttraumatic Vertigo presents with vertigo, disequilibrium, tinnitus, and headache following head trauma 2, 3

Medication-Induced Peripheral Vestibular Lesions

• Ototoxic medications, particularly aminoglycosides like gentamicin, can cause irreversible vestibular toxicity 2

  • Symptoms include dizziness, vertigo, tinnitus, and hearing loss 2

• Other medications including anticonvulsants (Mysoline, carbamazepine, phenytoin), antihypertensives, and cardiovascular drugs can cause vestibular symptoms 2

Central (Neurologic) Causes—Critical to Exclude

Life-Threatening Central Causes

• Stroke/Ischemia (brainstem and cerebellar) can mimic peripheral vestibular disorders 1, 3

  • 10% of cerebellar strokes present similar to peripheral vestibular processes 2, 3
  • 75-80% of stroke-related acute vestibular syndrome patients have no focal neurologic deficits, making stroke easy to miss 3
  • Vertigo may last minutes with nausea, vomiting, severe imbalance, visual blurring, and drop attacks 1
  • Insults are often permanent and do not fluctuate 1
  • May be comorbid with dysphagia, dysphonia, dysarthria, dysmetria, sensory or motor deficits, diplopia, or Horner's syndrome 1, 3
  • Usually no associated hearing loss or tinnitus 1

• Vertebrobasilar Insufficiency can present with isolated attacks of vertigo lasting less than 30 minutes without associated hearing loss 2

  • May precede stroke in the vertebrobasilar artery by weeks or months 2
  • Severe postural instability is characteristic 2
  • Gaze-evoked nystagmus is typical 2
  • Nystagmus does not fatigue and is not suppressed by gaze fixation 2

Other Central Causes

• Multiple Sclerosis often presents with progressive fluctuating bilateral hearing loss that is steroid responsive 1

  • May present with vision, skin, and joint problems 1
  • Listed among central causes that produce vertigo with associated autonomic symptoms including vomiting 3

• Vestibular Schwannoma (cerebellopontine angle tumors) may present with vertigo 1

  • Majority present with chronic imbalance and asymmetric hearing loss and tinnitus 1
  • Chronic imbalance more likely than profound episodic vertigo 1
  • Hearing loss does not typically fluctuate 1

• Posterior fossa masses present as chronic vestibular syndrome with dizziness lasting weeks to months 2

• Intracranial tumors and demyelinating diseases can cause central vertigo 3

Infectious and Inflammatory Central Causes

• Otosyphilis presents with 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

• Lyme disease (bacterial) can lead to complete hearing loss and vestibular crisis event with prolonged vertigo and/or hearing loss 1

  • Losses are often permanent and do not fluctuate 1
  • Can present with severe otalgia and fever 1

Critical Red Flags Demanding Immediate Neuroimaging

• Severe postural instability with falling is a primary distinguishing feature of central vertigo 2, 3
• New-onset severe headache with vertigo may indicate vertebrobasilar stroke or hemorrhage 2, 3
• Downbeating nystagmus on Dix-Hallpike without torsional component 2, 3
• Direction-changing nystagmus without head position changes (periodic alternating nystagmus) 3
• Direction-switching nystagmus (beats right with right gaze, left with left gaze) 3
• Baseline nystagmus without provocative maneuvers 2, 3
• Nystagmus that does not fatigue with repeated testing and is not suppressed by gaze fixation 2
• Gaze-evoked nystagmus 2
• Any additional neurological symptoms (limb weakness, hemiparesis, truncal/gait ataxia, dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, Horner's syndrome) 1, 2, 3
• Failure to respond to appropriate peripheral vertigo treatments (canalith repositioning or vestibular rehabilitation) 2, 3
• Apogeotropic horizontal nystagmus on supine roll test 2
• Isolated positional downbeat nystagmus 2

Other Causes to Consider

• Autoimmune disorders often present with progressive fluctuating bilateral hearing loss that is steroid responsive 1
• Postural hypotension causes triggered episodes, particularly in older adults on multiple medications 3
• Anxiety or panic disorder can present as chronic vestibular syndrome 3
• Cervicogenic vertigo has variable presentation 3

Common Pitfalls to Avoid

• Approximately 25% of patients presenting with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 2
• Misdiagnosis of stroke is a major concern, as 10% of cerebellar strokes present similar to peripheral vestibular disorders 2
• Overlooking subtle neurological signs that may indicate central pathology 2
• Overlooking medication side effects as vestibulotoxic agents can cause peripheral vestibular lesions 2
• Failing to distinguish between fluctuating hearing loss (Ménière's disease) versus stable/absent hearing loss (vestibular migraine) 2
• Overlooking vestibular migraine as a diagnosis, as it is under-recognized despite being extremely common 2
• Failing to consider multiple concurrent vestibular disorders, such as BPPV with Ménière's disease or vestibular neuritis 2