What are the causes of vertigo in different age groups and demographics?

Causes of Vertigo Across Age Groups and Demographics

Most Common Peripheral Vestibular Causes

Benign Paroxysmal Positional Vertigo (BPPV) is the single most common cause of vertigo overall, accounting for 42% of cases in general practice settings. 1

BPPV Characteristics

• Episodes last less than 1 minute, triggered by specific head position changes 1
• Results from mobile debris (canaliths) in the vestibular labyrinth 1
• No associated hearing loss, tinnitus, or aural fullness 1
• Diagnosed with Dix-Hallpike maneuver showing torsional and upbeating nystagmus with 5-20 second latency, crescendo-decrescendo pattern, and resolution within 60 seconds 2

Vestibular Neuritis

• Accounts for approximately 41% of peripheral vertigo cases in non-specialty settings 1
• Acute onset of severe rotational vertigo lasting 12 to 36 hours 1
• Caused by viral infection of the vestibular system 1
• No hearing loss distinguishes it from labyrinthitis 3

Ménière's Disease

• Accounts for 10% of vertigo cases in general practice, but up to 43% in specialty settings 1
• Episodes last 20 minutes to 12 hours 1
• The key distinguishing feature is fluctuating sensorineural hearing loss that worsens over time, plus tinnitus and aural fullness in the affected ear 1, 2

Central (Neurologic) Causes

Approximately 25% of patients presenting with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts. 1

Vertebrobasilar Insufficiency

• Presents with isolated attacks of vertigo lasting less than 30 minutes without associated hearing loss 1
• May precede stroke in the vertebrobasilar artery by weeks or months 1
• Characterized by severe postural instability, gaze-evoked nystagmus that does not fatigue, and nystagmus not suppressed by gaze fixation 2

Migraine-Associated Vertigo (Vestibular Migraine)

• Accounts for up to 14% of all vertigo cases 4, 2
• Lifetime prevalence of 3.2%, extremely common in young women 2
• Episodes can be short (<15 minutes) or prolonged (>24 hours) 2
• Requires at least two of the following during vertiginous episodes: migrainous headache, photophobia, phonophobia, or visual aura 4
• Hearing loss is typically mild, absent, or stable over time—NOT fluctuating like Ménière's disease 2

Stroke and Serious Central Causes

• Approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders 2
• Multiple sclerosis often presents with progressive fluctuating bilateral hearing loss that is steroid responsive 1

Age-Specific Considerations

Young Adults (20s-30s)

• Vestibular migraine is extremely common and often under-recognized in this demographic 5
• BPPV can occur but is less common than in older adults 5
• Anxiety disorders and medication side effects should be considered for chronic dizziness 5

Older Adults

• BPPV becomes increasingly common with age 6
• Vascular causes (vertebrobasilar insufficiency, stroke) increase significantly with age 1
• Medication side effects from antihypertensives, cardiovascular drugs, and anticonvulsants are more prevalent 1, 2

Critical Red Flags Demanding Immediate Neuroimaging

Any of the following require urgent MRI brain with diffusion-weighted imaging: 1, 2

• Severe postural instability with falling
• New-onset severe headache with vertigo
• Downbeating nystagmus on Dix-Hallpike without torsional component
• Any additional neurological symptoms: limb weakness, hemiparesis, truncal/gait ataxia, dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, or Horner's syndrome
• Baseline nystagmus present without provocative maneuvers
• Direction-changing nystagmus without changes in head position
• Failure to respond to appropriate peripheral vertigo treatments

Distribution by Clinical Setting

Non-Specialty (General Practice) Settings 4, 1

• BPPV: 42%
• Vestibular neuritis: 41%
• Ménière's disease: 10%
• Vascular causes: 3%
• Other causes: 3%

Subspecialty Settings 4

• Ménière's disease: 43%
• Vestibular neuritis: 26%
• BPPV: 23%

Common Pitfalls to Avoid

• Misdiagnosis of stroke is a major concern—brainstem and cerebellar strokes can mimic peripheral vestibular disorders, and 75-80% of posterior circulation strokes have no focal deficits 5
• Overlooking vestibular migraine, which is under-recognized despite being extremely common 2
• Failing to distinguish between fluctuating hearing loss (Ménière's disease) and stable/absent hearing loss (vestibular migraine) 2
• Overlooking medication side effects, particularly from ototoxic medications like aminoglycosides, which can cause irreversible vestibular toxicity 2
• Relying on patient's description of "spinning" versus "lightheadedness" instead of focusing on timing and triggers 5