What are the differences between Meniere’s disease and acute peripheral vertigo regarding symptoms, diagnostic findings, and management?

Distinguishing Menière's Disease from Acute Peripheral Vertigo

Menière's disease is a specific subtype of peripheral vertigo characterized by the triad of recurrent vertigo attacks lasting 20 minutes to 12 hours, fluctuating low-to-mid frequency sensorineural hearing loss, and fluctuating aural symptoms (tinnitus, ear fullness), whereas acute peripheral vertigo is a broader category encompassing multiple conditions with distinct temporal patterns and associated features. 1

Key Diagnostic Distinctions

Duration of Vertigo Episodes

The duration of vertigo is the single most important distinguishing feature:

• Menière's disease: Episodes last 20 minutes to 12 hours by definition 1, 2
• BPPV (most common acute peripheral vertigo): Episodes last seconds to less than 1 minute, triggered by specific head position changes 1, 3
• Vestibular neuritis: Single prolonged episode lasting days to weeks (12-36 hours of severe rotational vertigo, followed by 4-5 days of decreasing disequilibrium) 1
• Labyrinthitis: Sudden severe vertigo lasting more than 24 hours with profound hearing loss 1

Associated Auditory Symptoms

Menière's disease is distinguished by its characteristic fluctuating hearing pattern:

• Menière's disease: Audiometrically documented fluctuating low-to-mid frequency sensorineural hearing loss in the affected ear, with tinnitus and aural fullness that fluctuate with attacks 1, 4
• BPPV: No hearing loss, tinnitus, or aural fullness 1, 5
• Vestibular neuritis: No hearing loss, tinnitus, or aural fullness 1
• Labyrinthitis: Profound hearing loss that does not fluctuate and is typically permanent 1

Temporal Pattern of Attacks

The pattern of recurrence differs significantly:

• Menière's disease: Recurrent spontaneous attacks occurring over months to years, with at least two documented episodes required for diagnosis 1, 6
• BPPV: Triggered episodes only with specific head movements (Dix-Hallpike positive), not spontaneous 1, 3
• Vestibular neuritis: Typically a single monophasic event, though some patients may have recurrence 1

Diagnostic Workup Differences

For Suspected Menière's Disease

Confirm true vertigo (rotational spinning sensation) rather than vague dizziness, as many patients use imprecise terminology 1, 2

Obtain comprehensive audiometry to document:

• Low-to-mid frequency sensorineural hearing loss pattern 1
• Fluctuation in hearing thresholds (may require serial audiograms) 1, 4
• Pure tone average and word recognition scores 1

Consider MRI of the brain and internal auditory canals with and without contrast for:

• Unilateral or pulsatile tinnitus to exclude vestibular schwannoma 3
• Asymmetric hearing loss 3
• Atypical presentation requiring definitive diagnosis 3

Electrocochleography may show elevated summating potential/action potential ratio, though this is not required for diagnosis 1

For Suspected Acute Peripheral Vertigo (Non-Menière's)

Perform Dix-Hallpike maneuver bilaterally for BPPV diagnosis, looking for:

• Latency period of 5-20 seconds 3, 5
• Torsional upbeating nystagmus toward the affected ear 3
• Vertigo and nystagmus that increase then resolve within 60 seconds 3

No imaging or vestibular testing is needed for typical BPPV with positive Dix-Hallpike and no red flags 3

For acute persistent vertigo (vestibular neuritis), perform HINTS examination (when trained) to exclude stroke:

• Normal head impulse test suggests central cause 3
• Direction-changing or vertical nystagmus suggests central cause 3
• Present skew deviation suggests central cause 3

Critical Red Flags Requiring Urgent Neuroimaging

These features mandate immediate MRI brain without contrast to exclude stroke, even in presumed peripheral vertigo:

• Focal neurological deficits on examination 3, 5
• Sudden unilateral hearing loss 3, 5
• Inability to stand or walk 3, 5
• Downbeating nystagmus or other central nystagmus patterns 3, 5
• New severe headache accompanying dizziness 3
• High vascular risk factors (age >50, hypertension, diabetes, prior stroke) with acute vestibular syndrome 3

Management Approach Differences

Menière's Disease Management

Dietary and lifestyle modifications as first-line therapy:

• Sodium restriction to 1500-2300 mg/day maximum 2
• Limit caffeine, alcohol, and nicotine 2
• Adequate hydration with water 2
• Stress management through sleep, exercise, meditation 2

Medical management for persistent symptoms:

• Diuretics (though evidence is limited) 1, 7
• Betahistine (commonly used in Europe) 1, 7
• Oral steroids for acute attacks 1

Intratympanic gentamicin for refractory vertigo when medical management fails 1, 6, 7

Endolymphatic sac decompression surgery for patients who fail conservative and medical management 1

Acute Peripheral Vertigo (BPPV) Management

Canalith repositioning procedures (Epley maneuver) as first-line treatment:

• 80% success rate after 1-3 treatments 3, 5
• 90-98% success with repeat maneuvers if initial treatment fails 3, 5
• No medications needed for typical BPPV 3

Reassess within one month to document resolution or persistence 3

Vestibular rehabilitation therapy for persistent dizziness after initial treatment 3

Vestibular Neuritis Management

Vestibular suppressants (antiemetics, benzodiazepines) for acute phase only 1

Early vestibular rehabilitation therapy to promote central compensation 1

Corticosteroids may be considered in the acute phase, though evidence is mixed 7

Common Diagnostic Pitfalls

Do not rely on patient descriptions of "spinning" versus "lightheadedness"—focus instead on timing, triggers, and associated symptoms 1, 3

Vestibular migraine can mimic Menière's disease with similar duration attacks (minutes to hours), but typically lacks fluctuating hearing loss 1, 8

35% of Menière's patients also meet criteria for vestibular migraine, creating diagnostic overlap 3

Elderly patients with long-standing Menière's may present with vague dizziness rather than frank vertigo 1

75-80% of patients with posterior circulation stroke have no focal neurologic deficits, making stroke easy to miss in acute vestibular syndrome 5

Assuming normal neurologic exam excludes stroke is incorrect—use HINTS examination or obtain MRI in high-risk patients 3, 5