Vertigo Etiology: Distribution of Peripheral vs. Central Causes
Overall Distribution
Peripheral vestibular disorders account for approximately 75-80% of all vertigo cases, while central causes represent 20-25% of presentations. 1, 2
Most Common Specific Etiologies
Peripheral Causes (75-80% of all vertigo)
Benign Paroxysmal Positional Vertigo (BPPV) is the single most common cause of vertigo overall, accounting for 42% of cases in general practice settings and 23% in subspecialty settings. 1, 3
Vestibular neuritis represents approximately 41% of peripheral vertigo cases in non-specialty settings, presenting with acute onset severe rotational vertigo lasting 12-36 hours caused by viral infection of the vestibular system. 3
Ménière's disease accounts for 10% of vertigo cases in general practice and up to 43% in specialty settings, characterized by episodes lasting 20 minutes to 12 hours with fluctuating sensorineural hearing loss, tinnitus, and aural fullness. 1, 3
Labyrinthitis, superior canal dehiscence syndrome, posttraumatic vertigo, and perilymphatic fistula comprise the remaining peripheral causes. 1
Central Causes (20-25% of all vertigo)
Migraine-associated vertigo (vestibular migraine) accounts for up to 14% of all vertigo cases, with a lifetime prevalence of 3.2%, making it the most common central cause. 4, 3
Brainstem and cerebellar stroke account for approximately 3% of vertigo cases in general practice settings, though this rises dramatically to 25% of acute vestibular syndrome presentations and 75% in high vascular risk cohorts. 1, 4, 3
Vertebrobasilar insufficiency presents with isolated transient vertigo lasting less than 30 minutes without hearing loss, and can precede stroke by weeks to months. 1, 4, 3
Multiple sclerosis and other demyelinating diseases account for approximately 4% of acute vestibular syndrome cases. 1
Posterior fossa tumors, medication-induced central dizziness (Mysoline, carbamazepine, phenytoin, antihypertensives, cardiovascular drugs), and neurodegenerative disorders comprise the remaining central causes. 1, 4, 2
Critical Context for Clinical Practice
The distribution shifts dramatically based on clinical setting and risk factors. In patients presenting with acute vestibular syndrome (continuous dizziness lasting days), approximately 25% have cerebrovascular disease in unselected populations, but this jumps to 75% in high vascular risk cohorts. 1, 3
A major clinical pitfall is that 10% of cerebellar strokes present identically to peripheral vestibular disorders, and 75-80% of stroke-related acute vestibular syndrome cases present without focal neurologic deficits. 1, 3 This underscores why red-flag features (severe postural instability with falling, new severe headache, downbeating nystagmus without torsional component, failure to respond to peripheral vertigo treatments) mandate immediate neuroimaging even when the presentation appears "peripheral." 1, 3
The key to accurate diagnosis lies in categorizing vertigo by timing pattern rather than patient descriptions: triggered episodic (<1 minute, position-provoked = BPPV), spontaneous episodic (minutes to hours = vestibular migraine, Ménière's, vertebrobasilar TIA), acute vestibular syndrome (days = vestibular neuritis, labyrinthitis, stroke), and chronic (weeks to months = medication effects, anxiety, posterior fossa masses). 1