What are the differential diagnoses for vertigo?

Differential Diagnosis of Vertigo

Vertigo should be classified by timing and triggers—not by patient descriptions—to distinguish benign peripheral causes from life-threatening central pathology, with the most common etiologies being BPPV (42% of cases), vestibular neuritis (41%), and posterior circulation stroke (25% of acute vestibular syndrome, rising to 75% in high-risk patients). 1

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Classification by Temporal Pattern

Triggered Episodic Vertigo (Seconds to <1 Minute)

• Benign Paroxysmal Positional Vertigo (BPPV) – Brief episodes provoked by specific head-position changes (rolling over, looking up, bending forward); accounts for 42% of all vertigo presentations 1, 2
• Postural hypotension – Triggered by standing from supine; suggests cardiovascular rather than vestibular etiology 1, 3
• Superior canal dehiscence syndrome – Abnormal bone opening over the superior semicircular canal causing triggered episodes 1, 2
• Perilymphatic fistula – Abnormal middle-to-inner ear communication causing pressure-triggered vertigo 1, 2

Acute Persistent Vertigo (Days to Weeks)

• Vestibular neuritis – Sudden severe vertigo lasting >24 hours with profound nausea/vomiting; 41% of peripheral vertigo cases; no hearing loss 1, 3, 2
• Labyrinthitis – Similar to vestibular neuritis but with associated hearing loss 1, 3
• Posterior circulation stroke – 25% of acute vestibular syndrome overall; 75% in patients >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke); 75–80% present without focal neurologic deficits 1, 3, 4
• Cerebellar hemorrhage – Life-threatening; may mimic peripheral vestibulopathy but shows severe postural instability with falling 1, 5

Spontaneous Episodic Vertigo (Minutes to Hours)

• Vestibular migraine – Episodes lasting 5 minutes to >24 hours; 14% of all vertigo cases but markedly under-recognized; characterized by migraine history, photophobia, phonophobia, visual aura; stable or absent hearing loss distinguishes from Ménière's 1, 3, 2
• Ménière's disease – Episodes lasting 20 minutes to 12 hours; classic triad of fluctuating low-to-mid frequency sensorineural hearing loss, tinnitus, and aural fullness; 10% of general practice cases, 43% in specialty settings 1, 3, 2
• Vertebrobasilar insufficiency (TIA) – Episodes <30 minutes; no hearing loss; gaze-evoked nystagmus that does not fatigue; may precede stroke by weeks to months 1, 3, 2

Chronic Vestibular Syndrome (Weeks to Months)

• Medication side effects – Leading reversible cause; review antihypertensives, sedatives, anticonvulsants, psychotropic drugs, aminoglycosides, cardiovascular medications 1, 3, 2
• Anxiety/panic disorder – Can cause both lightheadedness (via hyperventilation) and true vestibular dysfunction 1, 3, 2
• Posttraumatic vertigo – Persistent vertigo, disequilibrium, tinnitus, headache following head trauma; trauma can also trigger BPPV 1, 3, 2
• Posterior fossa mass – Progressive symptoms; requires MRI for exclusion 1, 3
• Cervical vertigo – Associated with degenerative cervical spine disease; triggered by head rotation relative to body in upright posture 2

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Critical Red Flags Requiring Urgent MRI

Any of the following mandate immediate MRI brain without contrast (with diffusion-weighted imaging) and neurologic consultation: 1, 3

• Severe postural instability with falling – Distinguishes central from peripheral causes 1, 3
• New-onset severe headache with vertigo – May indicate vertebrobasilar stroke or hemorrhage 1, 3
• Focal neurologic deficits – Dysarthria, dysmetria, dysphagia, limb weakness, hemiparesis, diplopia, Horner's syndrome 1, 3, 6
• Sudden unilateral hearing loss – Requires urgent evaluation 1, 3
• Downbeating nystagmus on Dix-Hallpike without torsional component 1, 6
• Pure vertical nystagmus (up-beating or down-beating) without rotatory component 1, 3
• Direction-changing nystagmus without head-position changes 1, 3
• Baseline nystagmus present without provocative maneuvers 1, 3
• Nystagmus not suppressed by visual fixation and does not fatigue with repeated testing 1, 3, 2
• Gaze-evoked nystagmus – Typical of central lesions 1, 3
• Failure to respond to appropriate peripheral vertigo treatments (e.g., Epley maneuver) 1, 3, 6
• Apogeotropic horizontal nystagmus on supine roll test 1, 6
• Isolated positional downbeat nystagmus 1, 6
• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke) presenting with acute vestibular syndrome—even with normal neurologic exam—because 11–25% harbor posterior circulation stroke 3

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Key Distinguishing Features

Nystagmus Characteristics

Feature	Peripheral	Central
Direction	Horizontal with rotatory component, unidirectional	Pure vertical without torsional component; direction-changing or gaze-switching [1]
Visual fixation	Suppressed [1]	Not suppressed [1,2]
Fatigability	Fatigues with repeated testing [1]	Does not fatigue [1,2]
Latency	5–20 seconds before onset [1]	Immediate onset [1]
Duration	Resolves within 60 seconds [1]	Persistent [1]

Episode Duration by Diagnosis

• Seconds (<1 minute) – BPPV 1, 3
• Minutes to hours – Vestibular migraine, Ménière's disease, vertebrobasilar TIA 1, 3
• 20 minutes to 12 hours – Ménière's disease (by definition) 3
• <30 minutes – Vertebrobasilar insufficiency 1, 3
• Days to weeks – Vestibular neuritis, labyrinthitis, posterior circulation stroke 1, 3

Hearing Loss Patterns

• Fluctuating low-to-mid frequency sensorineural hearing loss – Ménière's disease 1, 3
• Stable or absent hearing loss – Vestibular migraine 1, 3
• Sudden profound non-fluctuating hearing loss – Labyrinthitis 3
• No hearing loss – BPPV, vestibular neuritis, vertebrobasilar insufficiency 1, 3
• Asymmetric or unilateral hearing loss – Mandates urgent MRI to exclude vestibular schwannoma or stroke 3

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Common Diagnostic Pitfalls

• Relying on patient descriptions ("spinning" vs. "lightheadedness") is unreliable; focus on timing, triggers, and associated symptoms 1, 3
• Assuming normal neurologic exam excludes stroke – 75–80% of posterior circulation strokes present without focal deficits 1, 3
• Overlooking vestibular migraine – Extremely common (14% of cases) but under-recognized, especially in young women 1, 3
• Failing to distinguish fluctuating hearing loss (Ménière's) from stable/absent hearing loss (vestibular migraine) 1, 3
• Missing medication side effects – Leading reversible cause of chronic dizziness 1, 3
• Approximately 10% of cerebellar strokes present similar to peripheral vestibular disorders 1
• Isolated transient vertigo may precede stroke by weeks to months in vertebrobasilar insufficiency 1, 3
• Multiple concurrent vestibular disorders can coexist (e.g., BPPV with Ménière's disease or vestibular neuritis) 1

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Less Common but Important Causes

• Autoimmune inner ear disease – Progressive fluctuating bilateral hearing loss with vertigo; may have vision, skin, joint problems 2
• Otosyphilis – Can mimic Ménière's disease with fluctuating hearing loss 3
• Lyme disease – Infectious cause; can lead to complete hearing loss and vestibular crisis 2
• Multiple sclerosis – Progressive fluctuating bilateral hearing loss with vertigo and vision problems; 4% of acute vestibular syndrome cases 1, 2
• Vestibular schwannoma – Requires MRI with contrast for chronic recurrent vertigo with unilateral hearing loss or tinnitus 3
• Ototoxic medications – Particularly aminoglycosides (gentamicin); may cause irreversible vestibular toxicity 1

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Diagnostic Approach Algorithm

1. Classify by timing and triggers (not patient description) 1, 3
2. Perform Dix-Hallpike maneuver bilaterally for triggered episodic symptoms 1, 3
3. If positive Dix-Hallpike with typical nystagmus (torsional, up-beating, latency, fatigability, <60 seconds) and no red flags → diagnose BPPV; no imaging needed 1, 3
4. If acute persistent vertigo, perform HINTS examination (by trained examiner) 1, 3, 4
5. Assess for red flags (see list above) 1, 3
6. If any red flag present → urgent MRI brain without contrast with diffusion-weighted imaging 1, 3
7. Evaluate hearing – Audiometry to distinguish fluctuating (Ménière's) vs. stable/absent (vestibular migraine) vs. sudden profound (labyrinthitis) 1, 3
8. Review medications systematically for reversible causes 1, 3
9. Screen for migraine features – Current/past migraine history, family history, photophobia, phonophobia, visual aura during ≥50% of episodes 1, 3
10. Assess vascular risk factors in patients >50 years (hypertension, diabetes, atrial fibrillation, prior stroke) 1, 3

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Response to Treatment as Diagnostic Clue

• Peripheral vertigo (BPPV) responds to canalith repositioning procedures (Epley maneuver); 80% success after 1–3 treatments, 90–98% with repeat maneuvers 1, 3
• Central vertigo does not respond to repositioning procedures 1
• Failure to respond to appropriate peripheral vertigo treatments is a red flag for central pathology 1, 3, 6

1, 3, 2, 7, 6, 8, 5, 4