What are the causes of peripheral vertigo and how can each be differentiated clinically?

Causes of Peripheral Vertigo and Clinical Differentiation

Major Causes of Peripheral Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) is the most common peripheral vestibular disorder, accounting for 42% of all vertigo cases in general practice, followed by vestibular neuritis at 41%, and Ménière's disease at 10% in primary care settings. 1

1. Benign Paroxysmal Positional Vertigo (BPPV)

Clinical Features:

• Episodes last <1 minute (typically 5–60 seconds) 2
• Triggered exclusively by specific head-position changes relative to gravity (rolling over in bed, looking up, bending forward, lying down) 2
• True rotational vertigo with 5–20 second latency after position change 2
• No hearing loss, tinnitus, or aural fullness 2
• Nausea may occur but hearing remains normal 2

Diagnostic Testing:

• Dix-Hallpike maneuver (performed bilaterally) produces torsional upbeating nystagmus toward the affected ear with 5–20 second latency, crescendo-decrescendo pattern, and resolution within 60 seconds 1, 2
• Supine roll test identifies lateral-canal BPPV (10–15% of cases) with horizontal nystagmus 1, 3
• Nystagmus fatigues with repeated testing 2

Pathophysiology:

• Dislodged otoconia migrate into semicircular canals (85–95% posterior canal, 5–15% lateral canal) 2

2. Vestibular Neuritis

Clinical Features:

• Acute onset of severe continuous vertigo lasting days to weeks (typically 12–36 hours of severe vertigo, followed by 4–5 days of decreasing disequilibrium) 1
• Constant symptoms, not triggered by position changes 1
• No hearing loss, tinnitus, or aural fullness 1
• Severe nausea, vomiting, and gait instability 1

Diagnostic Testing:

• Unidirectional horizontal nystagmus that persists without positional changes 4, 5
• Abnormal head-impulse test (corrective saccade when head turned toward affected side) 6
• Normal hearing on audiometry 1

Pathophysiology:

• Presumed inflammatory or ischemic injury to vestibular nerve 6

3. Ménière's Disease

Clinical Features:

• Episodic attacks lasting 20 minutes to 12 hours 1
• Fluctuating low-to-mid frequency sensorineural hearing loss (key distinguishing feature) 4, 1
• Aural fullness and tinnitus in affected ear that vary with attacks 4, 1
• At least two documented spontaneous vertigo episodes required for diagnosis 1

Diagnostic Testing:

• Comprehensive audiometry documents fluctuating low-to-mid frequency sensorineural hearing loss 1
• Hearing loss worsens over time with repeated attacks 1
• Electrocochleography may show elevated summating-potential/action-potential ratio (optional) 1

Pathophysiology:

• Endolymphatic hydrops 4

4. Labyrinthitis

Clinical Features:

• Sudden severe vertigo persisting >24 hours 1
• Profound, permanent, non-fluctuating hearing loss (distinguishes from Ménière's) 1
• Severe nausea and vomiting 1

Diagnostic Testing:

• Audiometry shows profound sensorineural hearing loss that does not fluctuate 1
• Unidirectional horizontal nystagmus 1

Pathophysiology:

• Inflammation of inner ear affecting both vestibular and cochlear structures 3

5. Superior Canal Dehiscence (SCD)

Clinical Features:

• Vertigo induced by pressure changes (Valsalva, coughing, straining), not position changes 4
• May present with conductive hearing loss (lower bone-conducted thresholds) 4
• Sound-induced vertigo (Tullio phenomenon) 4

Diagnostic Testing:

• CT temporal bone shows dehiscence in bone covering superior semicircular canal 4
• Vestibular evoked myogenic potential (VEMP) testing shows abnormally low thresholds 4

6. Perilymph Fistula

Clinical Features:

• Episodes of vertigo and nystagmus triggered by pressure changes 4
• May occur after middle ear or mastoid surgery, or spontaneously 4
• Fluctuating hearing loss may accompany symptoms 4

Diagnostic Testing:

• Clinical diagnosis based on pressure-triggered symptoms 4
• May require exploratory tympanotomy for definitive diagnosis 4

7. Vestibular Migraine

Clinical Features:

• Episodes lasting 5 minutes to 72 hours 4, 1
• Accounts for 14% of all vertigo cases but markedly under-recognized 1
• Stable or absent hearing loss (key distinction from Ménière's) 1, 3
• Migraine symptoms during ≥50% of dizzy episodes (headache, photophobia, phonophobia, visual aura) 4, 1
• Motion intolerance and light sensitivity as triggers 3

Diagnostic Criteria:

• ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours 4
• Current or history of migraine by International Headache Society criteria 4
• ≥1 migraine symptom during at least 50% of dizzy episodes 4

8. Posttraumatic Vertigo

Clinical Features:

• History of head trauma 4, 1
• Persistent vertigo, disequilibrium, tinnitus, and headache 4, 1
• May be complicated by depression or anxiety 4
• Traumatic brain injury is associated with BPPV 4

9. Vertebrobasilar Insufficiency (Peripheral Manifestation)

Clinical Features:

• Brief episodes <30 minutes 1
• No hearing loss 1
• Gaze-evoked nystagmus that does not fatigue 1
• May precede posterior circulation stroke by weeks to months 1
• Severe postural instability 1

Risk Factors:

• Age >50 years, hypertension, diabetes, atrial fibrillation, prior stroke 1

Critical Differentiation Algorithm

Step 1: Duration of Episodes

• Seconds (<1 minute): BPPV 1, 2
• Minutes to hours: Vestibular migraine or Ménière's disease 1
• Days to weeks (continuous): Vestibular neuritis or labyrinthitis 1
• <30 minutes (recurrent): Vertebrobasilar insufficiency 1

Step 2: Triggers

• Specific head-position changes: BPPV 2
• Pressure changes (Valsalva): SCD or perilymph fistula 4
• Spontaneous (no trigger): Vestibular migraine, Ménière's, vestibular neuritis 1

Step 3: Hearing Symptoms

• Fluctuating hearing loss + tinnitus + aural fullness: Ménière's disease 4, 1
• Profound permanent hearing loss: Labyrinthitis 1
• Stable/absent hearing loss with migraine features: Vestibular migraine 1, 3
• No hearing symptoms: BPPV, vestibular neuritis, vertebrobasilar insufficiency 1, 2

Step 4: Nystagmus Pattern

• Torsional upbeating with latency and fatigability: BPPV (posterior canal) 2
• Horizontal with latency and fatigability: BPPV (lateral canal) 3
• Unidirectional horizontal, persistent: Vestibular neuritis 5
• Gaze-evoked, non-fatiguing: Vertebrobasilar insufficiency 1

Step 5: Perform Dix-Hallpike Maneuver

• Positive (characteristic nystagmus): BPPV confirmed 1, 2
• Negative: Proceed to supine roll test for lateral-canal BPPV 3
• Atypical findings (immediate onset, purely vertical, persistent): Consider central pathology 3, 7

Red Flags Requiring Urgent Neuroimaging (Central Causes)

Any of the following mandate immediate MRI brain without contrast:

• Downbeating or purely vertical nystagmus without torsional component 4, 3
• Direction-changing nystagmus without head-position changes 4, 3
• Baseline nystagmus without provocative maneuvers 4, 3
• Severe postural instability with falling 1, 3
• Focal neurological deficits (dysarthria, limb weakness, diplopia, Horner's syndrome) 1, 3
• New severe headache with vertigo 1, 3
• Sudden unilateral hearing loss 1
• Failure to respond to appropriate peripheral vertigo treatments 4, 3
• Normal head-impulse test in acute vestibular syndrome 1, 6

Note: 75–80% of posterior circulation strokes present without focal neurologic deficits, making clinical examination alone insufficient to exclude stroke. 1

Common Diagnostic Pitfalls

• Relying on patient descriptions of "spinning" versus "lightheadedness" is unreliable; focus on timing, triggers, and associated symptoms 1
• Assuming normal neurologic exam excludes stroke is dangerous, as most posterior circulation strokes lack focal deficits 1
• Overlooking vestibular migraine, which is extremely common (14% of cases) but under-recognized, especially in young patients 1, 3
• Failing to distinguish fluctuating hearing loss (Ménière's) from stable/absent hearing loss (vestibular migraine) 1, 3
• Missing medication-induced dizziness, a leading reversible cause of chronic vestibular symptoms (review antihypertensives, sedatives, anticonvulsants, psychotropic drugs) 1
• Approximately 50% of BPPV patients describe symptoms as "lightheadedness" or "off-balance" rather than classic spinning vertigo—always perform Dix-Hallpike regardless of description 1
• Multiple peripheral vestibular disorders can coexist (e.g., BPPV with Ménière's or vestibular neuritis) 3