What is the differential diagnosis and management approach for a patient presenting with vertigo and dysphagia?

Differential Diagnosis: Vertigo and Dysphagia

Immediate Life-Threatening Consideration

The combination of vertigo and dysphagia is a red flag for posterior circulation stroke until proven otherwise, and demands immediate neuroimaging. 1, 2

• Dysphagia is a critical distinguishing feature that separates central (stroke) from peripheral vestibular causes 1, 2
• Posterior circulation stroke presents with vertigo lasting minutes, severe imbalance, nausea, and vomiting, often accompanied by dysphagia, dysarthria, visual blurring, drop attacks, or limb weakness 1, 2
• These neurological deficits are permanent and non-fluctuating, unlike peripheral vestibular disorders 1
• Approximately 25% of patients with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 3

Critical Red Flags Requiring Emergency Neuroimaging

Beyond dysphagia, the following demand immediate imaging 2, 3:

• Direction-changing nystagmus without head position changes 2, 3
• Downbeating nystagmus 2, 3
• Severe postural instability disproportionate to vertigo 1, 2
• Any focal neurological deficits (dysarthria, limb weakness, sensory deficits, Horner's syndrome) 2, 3
• Baseline nystagmus without provocative maneuvers 2, 3
• New-onset severe headache with vertigo 2, 3

Differential Diagnosis Algorithm

Step 1: Exclude Central Causes (Stroke Priority)

Perform targeted neurological examination for 2:

• Dysarthria (speech difficulty)
• Dysphagia (swallowing difficulty)
• Visual disturbances (diplopia, visual field defects)
• Motor/sensory deficits (limb weakness, numbness)
• Horner's syndrome (ptosis, miosis, anhidrosis)
• Severe truncal/gait ataxia

If ANY of these are present: Emergency MRI is required 2, 4

Step 2: Characterize Nystagmus Pattern

Central vertigo nystagmus characteristics 3:

• Pure vertical (upbeating or downbeating) without torsional component
• Direction-changing without changes in head position
• Not suppressed by visual fixation
• Persistent without modification on repositioning maneuvers

Peripheral vertigo nystagmus characteristics 3:

• Horizontal with rotatory component
• Unidirectional
• Suppressed by visual fixation
• Fatigable with repeated testing
• Brief latency period before onset

Step 3: Determine Timing Pattern

Duration helps narrow the differential 1, 2:

• Seconds: Benign paroxysmal positional vertigo (BPPV) 1
• Minutes: Posterior circulation stroke/TIA, vertebrobasilar insufficiency 1, 2
• Hours: Ménière's disease, vestibular migraine 1
• >24 hours: Vestibular neuritis, labyrinthitis 1

Step 4: Assess for Infectious/Inflammatory Causes

If fever is present with vertigo and dysphagia 2:

• Viral or bacterial infection can cause complete hearing loss and vestibular crisis with prolonged vertigo 1, 2
• Vestibular neuritis: Acute prolonged vertigo (12-36 hours) with severe rotational component, nausea, vomiting WITHOUT hearing loss, tinnitus, or aural fullness 1, 2
• Labyrinthitis: Sudden severe vertigo with profound hearing loss lasting >24 hours, not episodic or fluctuating 1
• Lyme disease or otosyphilis: Can present with fluctuating hearing loss and vertigo 1

Step 5: Consider Other Central Causes

Multiple sclerosis 1, 2:

• Progressive fluctuating bilateral hearing loss (steroid-responsive)
• May present with vision, skin, and joint problems
• Demyelinating lesions on MRI

Vestibular migraine 1, 2:

• Attacks lasting hours with photophobia
• Hearing loss less likely than Ménière's disease
• Migraine history often present

Posterior fossa mass lesions 1, 3:

• Chronic vestibular syndrome (weeks to months)
• Chronic imbalance more likely than episodic vertigo

Diagnostic Testing Approach

Imaging Recommendations

MRI is the gold standard 4:

• Sensitivity 79.8% (95% CI 71.4%-86.2%)
• Specificity 98.8% (95% CI 96.2%-100%)
• Will still miss approximately 1 in 5 strokes if obtained early after symptom onset 4

CT head without contrast has very limited utility 4:

• Sensitivity only 28.5% (95% CI 14.4%-48.5%)
• Specificity 98.9% (95% CI 93.4%-99.8%)
• Cannot be used to rule out stroke in acute vertigo 4

CTA has even lower sensitivity than CT 1, 4:

• Sensitivity 14.3% for central etiology
• Specificity 97.7%

Bedside Examination Tests

Dix-Hallpike maneuver 1, 3:

• Positive in BPPV: Torsional and upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, fatigues with repeat testing, resolves within 60 seconds
• Red flag for central cause: Immediate onset, persistent nystagmus, purely vertical without torsional component

HINTS examination (Head Impulse, Nystagmus, Test of Skew) 5:

• More sensitive than early MRI for posterior circulation stroke
• Abnormal head impulse test suggests peripheral cause
• Direction-changing nystagmus or skew deviation suggests central cause

Common Pitfalls to Avoid

1. Never dismiss dysphagia as anxiety when accompanied by vertigo 2 - This combination is stroke until proven otherwise

2. Do not overlook subtle neurological signs 2 - Always check for dysarthria, dysphagia, and visual changes even when vestibular symptoms are prominent

3. Do not delay imaging if vertigo persists >24 hours without improvement 2 - Or if any central features are present

4. Approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders 3 - Maintain high index of suspicion

5. Do not rely on CT head to exclude stroke 4 - Sensitivity is only 28.5%; MRI is required

6. Misdiagnosis of stroke as benign peripheral vertigo is the most dangerous error 3, 6 - The presence of dysphagia makes this combination high-risk

Management Implications

For confirmed peripheral causes 7:

• Meclizine 25-100 mg daily in divided doses for symptomatic relief
• Avoid prolonged use of vestibular suppressants as they interfere with central compensation 3
• Canalith repositioning procedures (Epley maneuver) for BPPV 3

For suspected central causes 2, 3:

• Immediate neuroimaging (MRI preferred)
• Neurology or stroke team consultation
• Do not prescribe vestibular suppressants until central cause excluded