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Vertigo is the false sensation of motion (e.g., spinning or swaying) caused by dysfunction of the inner ear (peripheral vertigo) or the central vestibular system (central vertigo). It is often confused with similar terms related to dizziness (e.g., disequilibrium, lightheadedness). Peripheral causes (e.g., benign paroxysmal positional vertigo, vestibular neuritis) are typically benign, while central causes (e.g., posterior stroke, tumors of the posterior fossa) can be life-threatening. Clinical features and neurological examination findings can help identify the underlying cause. Depending on the clinical presentation, targeted examination maneuvers may also be indicated. In patients with episodic, triggered vertigo, the can be used to confirm benign paroxysmal positional vertigo ( ), while in patients with acute vertigo without a clear trigger, (HINTS) examination can be used to assess for central causes (e.g., ). Urgent neuroimaging is indicated in patients with suspected central vertigo. Further testing, including laboratory studies, is not routinely required. Treatment depends on the underlying cause.
- Vertigo: the sensation of spinning or swaying of oneself (internal vertigo) or of one's surroundings (external vertigo) while stationary; caused by vestibular dysfunction due to asymmetric vestibular input and may be spontaneous or triggered 
- A nonvertiginous disturbance in spatial orientation without a false sensation of motion
- Often used by patients as an umbrella term to describe a variety of sensations, including vertigo, presyncope, imbalance, and confusion 
Vertigo can be caused by a variety of medical conditions, which are commonly divided into central and peripheral causes based on the location of involvement.
|Causes of vertigo |
|Type of vertigo||Definition||Diagnoses|
Vertigo is often accompanied by other signs and symptoms, which can help to identify the underlying cause. However, further evaluation is often necessary to establish a diagnosis and rule out life-threatening causes.
Clinical features alone cannot determine whether vertigo is peripheral or central in origin, as symptoms often overlap, e.g., movement can worsen symptoms of dizziness and/or vertigo in both peripheral and central causes. 
|Peripheral vs. central vertigo |
|Clinical features||Suggestive of peripheral vertigo||Suggestive of central vertigo|
|Neurological features|| |
Cranial nerve features
(See “” for details.)
| || |
|Hearing loss and/or tinnitus|| || |
| || |
Sense of motion (e.g., swaying, spinning)
| || |
|Nausea and/or vomiting|| || |
Any of the Dangerous D's (Dysphagia, Dysarthria, Diplopia, Dysmetria) strongly suggest a central cause of vertigo.
Patients are often classified into vestibular syndromes based on their clinical presentation (e.g., onset, triggers, and chronicity) in order to guide the diagnostic evaluation (e.g., Dix-Hallpike testing vs HINTS examination).
- Acute vestibular syndrome: the acute onset of continuous vertigo, gait instability, nystagmus, and nausea (with or without hearing loss) that may be worsened, but not triggered, by movement; usually lasts days to weeks 
- Episodic vestibular syndrome: recurrent episodes of vertigo often associated with gait instability and nausea that typically last seconds to hours; may be triggered or spontaneous 
- Chronic vestibular syndrome: the presence of continuous vestibular symptoms for weeks to years 
Clinical evaluation 
- Determine onset, triggers, and duration of vertigo.
- Identify the following:
- Associated features that may help
- Features of any underlying etiologies.
- Physical examination
Targeted examination maneuvers 
- Consider to screen for a central cause in without an identifiable trigger.
- Consider or other for a triggered .
When approaching a patient with vertigo, think TiTrATE: Timing, Triggers, And Targeted Examination. 
Consider further diagnostic studies depending on the suspected underlying disease or if the cause is still unknown; see “Diagnostic testing in vertigo” for details.
- Suspected central vertigo: Admit patients for further testing (e.g., neuroimaging) and treatment; see “ .”
High likelihood of peripheral vertigo (i.e., no signs suggestive of central vertigo)
- Usually, no further acute diagnostic testing is required; can begin empiric in most cases.
- Consider ENT referral for outpatient evaluation and follow-up.
- Chronic vertigo
Head impulse, nystagmus, test of skew (HINTS) examination 
- Indication: symptomatic patients with
- Objective: : to screen for central causes of vertigo, especially stroke 
- Next steps: If HINTS testing suggests a central cause of vertigo, begin urgent management and obtain neuroimaging. 
|Overview of HINTS examination |
|Suggestive of a peripheral cause||Suggestive of a central cause |
Head impulse test
Test of skew
| Interpretation  |
- Indication: clinical findings suggestive of a central cause of vertigo 
- Modality: MRI brain with or without magnetic resonance angiogram (MRA) 
Neuroimaging is indicated if clinical findings raise suspicion for a central cause of vertigo (e.g., cerebellar stroke, lateral medullary syndrome), especially in patients with any (e.g., age ≥ 65 years, multiple comorbidities).
Additional studies 
- Laboratory studies: Consider based on patient history. 
- ECG: to evaluate for suspected and/or arrhythmia
- Audiogram: to evaluate for sensorineural hearing loss (e.g., in Meniere disease, labyrinthitis, vestibular schwannoma)
Caloric testing (with electronystagmography): to detect a unilateral peripheral vestibulopathy 
- Procedure: Infuse cold water and, subsequently, warm water into each ear and document the elicited nystagmus. 
|Causes of peripheral vertigo|
|Characteristics of vertigo||Clinical features||Diagnostic approach|
|Vestibular neuritis and labyrinthitis|| |
|Benign paroxysmal positional vertigo|| |
|Meniere disease|| || |
Management of peripheral vertigo
- Identify and treat the underlying condition; based on clinical evaluation (e.g., BPPV) for suspected .
- Consider short-term symptomatic pharmacotherapy for acute vertigo, nausea, and vomiting. 
- Vestibular suppressants
- , e.g., ,
- if the diagnosis is unclear or a trial of therapy is unsuccessful, consider further and outpatient follow-up with specialist (e.g., ENT). o
- Consider vestibular rehabilitation therapy to help facilitate central vestibular compensation and accelerate recovery.
Vestibular suppressants 
- Definition: drugs that suppress the effects of vestibular dysfunction, such as vertigo, nystagmus, and nausea
- Meniere disease and vestibular neuritis: short-term pharmacotherapy for severe symptoms of an acute episode of peripheral vertigo
- BPPV: generally not recommended, but may be used: 
- First-generation antihistamines 
- Benzodiazepines 
Vestibular suppressants should only be used for short periods of time. Chronic use of vestibular suppressants is contraindicated because they can inhibit central compensation and potentially exacerbate chronic gait and postural instability. 
Counsel patients about potential adverse effects of vestibular suppressants (e.g., falls, cognitive dysfunction, drowsiness).
Vestibular rehabilitation 
- Definition: a set of physical exercises used to treat dizziness and balance disorders by inducing vestibular habituation, central vestibular compensation, and adaptation to gravitational changes to minimize the frequency of episodic vertigo
- Exercises: can include walking and balance exercises, controlled eye movements, and active head movements and may be tailored to the patient by a trained specialist and adapted depending on the underlying disease (e.g., , )
causes of vertigo and vary depending on the location of the lesion and/or dysfunction. Neurological examination may show involvement, which is suggestive of brainstem involvement, and/or signs of cerebellar dysfunction.are typically present in central
|Causes of central vertigo|
|Characteristics of vertigo||Clinical features||Diagnostic approach|
| || |
| (e.g., )|| |
Continuous, progressive vertigo followed by cerebellar tonsillar herniation) of posterior fossa tumors (e.g., , ). Obtain immediate neuroimaging and consult neurosurgery.  may suggest life-threatening complications (e.g.,
Management of central vertigo
- If central vertigo is suspected, consult neurology, obtain neuroimaging, and treat the underlying condition.
- In patients with acute vestibular syndrome and and/or abnormal HINTS testing:
This section lists common mimics of vertigo. For a comparison of different, see “ ” and “ .”
Cardiac and neurological disorders
- (e.g., )
- Noncardiac syncope (e.g., , )
- Other neurological vertigo mimics
Other causes of dizziness
- Metabolic abnormalities
- Adverse effects: i.e., of medications and other substances (e.g., alcohol, recreational drug use) 
- Functional dizziness: e.g., , ,
Motion sickness 
- Definition: a nonpathological acute condition characterized by dizziness, nausea, and autonomic symptoms caused by a mismatch in proprioceptive signals; depending on the means of locomotion, motion sickness is often referred to as seasickness, carsickness, or airsickness.
- Epidemiology: more frequent in children, women, and individuals with migraines and/or vestibular disorders
- Etiology: locomotion by any means of transportation (esp. boat) or a simulation thereof (e.g., while watching a film or playing video games)
- A mismatch of sensorial information that occurs when parts of the sensory apparatus report motion while others report being stationary
- Example: reading while driving; the eyes will report being stationary while the vestibular apparatus will report motion or, conversely, while watching a roller coaster simulation, the eyes will report motion, but the vestibular system will report being stationary
- Clinical features
Prevention and treatment
- Behavioral measures: avoid reading or watching videos and choose a forward-facing seat during transportation, focus the distant horizon, reduce head and body movements
- Medical treatment: most effective when used prophylactically
The differential diagnoses listed here are not exhaustive.
Special patient groups
Dizziness and vertigo in older adults 
- The prevalence of dizziness and vertigo increases with age.
- Age-related degeneration of the central and peripheral vestibular systems can cause vertigo; however, the etiology is more likely to be multifactorial.
- dizziness and vertigo include: that increase the risk of
- Identify the underlying cause following the standard . 
- Reduce the risk of and improve and/or maintain daily function and independence
- If severe symptoms require treatment, avoid sedatives and antihistamines if possible, or use them with caution.
- A combination of treatments may be required to address multiple contributing factors (e.g., medication adjustments to minimize adverse effects and balance training with physiotherapy).
Dizziness and unsteady gait are abnormal in older patients and should always be thoroughly investigated.