Vertigo

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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 Dix-Hallpike maneuver can be used to confirm benign paroxysmal positional vertigo (BPPV), while in patients with acute vertigo without a clear trigger, head impulse, nystagmus, test of skew (HINTS) examination can be used to assess for central causes (e.g., ischemic stroke). 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.

See also “Vestibular neuritis”, “Labyrinthitis”, “BPPV”, and “Meniere disease.”

• 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 ^[2][3]
• Dizziness ^[2][3]
  • 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 ^[4]

Do not confuse vertigo for presyncope, which refers to severe lightheadedness or near loss of consciousness; most commonly due to a drop in systemic blood pressure or hypoxia. ^[4][5]

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.

Stroke and acute obstructive hydrocephalus caused by a posterior fossa tumor are medical emergencies and require immediate management.

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. ^[5]

Associated features

Any of the Dangerous D's (Dysphagia, Dysarthria, Diplopia, Dysmetria) strongly suggest a central cause of vertigo.

Vestibular syndromes

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 ^[4][9][12]
• 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 ^[4]
• Chronic vestibular syndrome: the presence of continuous vestibular symptoms for weeks to years ^[4]

Clinical evaluation ^[3][4][5]

• Focused history
  • Determine onset, triggers, and duration of vertigo.
  • Identify the following:
    • Associated features that may help differentiate between central and peripheral vertigo
    • Risk factors for ischemic stroke
    • Features of any underlying etiologies.
• Physical examination
  • Perform orthostatic vital signs to rule out orthostatic presyncope.
  • Conduct a neurological examination that includes:
    • Evaluation of cerebellar features and full cranial nerve examination including:
      • Evaluation of nystagmus (e.g., identify spontaneous nystagmus and gaze-evoked nystagmus)
      • Examination of gait
    • Identification of any focal neurological deficits.
• Targeted examination maneuvers ^[5][11][12]
  • Consider HINTS examination to screen for a central cause in acute vestibular syndrome without an identifiable trigger.
  • Consider Dix-Hallpike maneuver or other provoking maneuvers for BPPV for a triggered episodic vestibular syndrome.

When approaching a patient with vertigo, think TiTrATE: Timing, Triggers, And Targeted Examination. ^[4]

Diagnostic approach

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 “Management of central vertigo.”
• High likelihood of peripheral vertigo (i.e., no signs suggestive of central vertigo)
  • Usually, no further acute diagnostic testing is required; can begin empiric management of peripheral vertigo in most cases.
  • Consider ENT referral for outpatient evaluation and follow-up.
• Chronic vertigo
  • Consider neuroimaging and laboratory studies.
  • Refer to ENT and/or Neurology to guide evaluation.

Obtain immediate neuroimaging to evaluate for central causes in patients with acute vertigo and focal neurological deficits and/or abnormal HINTS testing, especially if risk factors for ischemic stroke are present.

Head impulse, nystagmus, test of skew (HINTS) examination ^[9][12]

• Indication: symptomatic patients with acute vestibular syndrome
• Objective: : to screen for central causes of vertigo, especially stroke ^[9][11][12]
• Next steps: If HINTS testing suggests a central cause of vertigo, begin urgent management and obtain neuroimaging. ^[11][13]

Performing HINTS testing while the patient is asymptomatic increases the likelihood of a false-negative result. ^[9][14]

During HINTS testing, think INFARCT to identify central causes (e.g., stroke): Impulse Normal, Fast-phase Alternating, Refixation on Cover Test. ^[11]

Neuroimaging ^[3][9][17]

• Indication: clinical findings suggestive of a central cause of vertigo ^[15]
  • Focal neurological deficits
  • Concurrent severe headache
  • HINTS examination suggestive of central vertigo
  • Risk factors for ischemic stroke
• Modality: MRI brain with or without magnetic resonance angiogram (MRA) ^[3][18][19]
• Findings
  • Abnormal findings may be seen in patients with ischemic stroke, demyelination, or tumors.
  • Findings are typically normal in patients with peripheral causes (e.g., those with vestibular neuritis).

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 risk factors for ischemic stroke (e.g., age ≥ 65 years, multiple comorbidities).

Additional studies ^[3]

Additional studies may be performed if the cause of vertigo remains unknown or if patient history and/or physical examination suggest an alternative cause.

• Laboratory studies: Consider based on patient history. ^[5]
  • CBC, BMP, POC glucose, vitamin B₁₂
  • Serum drug levels (e.g., for anticonvulsants)
  • Urine toxicology screen
• ECG: to evaluate for suspected cardiogenic syncope 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 ^[20][21]
  • Procedure: Infuse cold water and, subsequently, warm water into each ear and document the elicited nystagmus. ^[10][15][22]
  • Interpretation
    • Normal caloric response
      • Cold water: nystagmus with the fast phase away from the stimulated ear
      • Warm water: nystagmus with the fast phase toward the stimulated ear
    • Unilaterally reduced or absent caloric response suggests a peripheral cause.

The direction of the fast component of the physiological nystagmus elicited with caloric testing can be remembered with the term COWS: Cold Opposite; Warm Same.

Etiology ^[3][5]

Management of peripheral vertigo

For detailed management of specific types of peripheral vertigo, see “Vestibular neuritis”, “Labyrinthitis”, “BPPV”, and “Meniere disease.”

• Identify and treat the underlying condition; based on clinical evaluation (e.g., Epley maneuver for suspected BPPV).
• Consider short-term symptomatic pharmacotherapy for acute vertigo, nausea, and vomiting. ^[23][24][25]
  • Vestibular suppressants
  • Antiemetics, e.g., metoclopramide, ondansetron
• if the diagnosis is unclear or a trial of therapy is unsuccessful, consider further diagnostics for vertigo and outpatient follow-up with specialist (e.g., ENT).
• Consider vestibular rehabilitation therapy to help facilitate central vestibular compensation and accelerate recovery.

Vestibular suppressants ^{[14][15][23][24][25]}

• Definition: drugs that suppress the effects of vestibular dysfunction, such as vertigo, nystagmus, and nausea
• Indications
  • 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: ^[24]
    • Prior to provoking or repositioning maneuvers
    • In patients who decline canalith repositioning maneuvers (CRM)
    • In patients with intractable symptoms
• First-generation antihistamines ^[23]
  • Meclizine ^[23]
  • Diphenhydramine (off-label) ^[23]
  • Dimenhydrinate
• Benzodiazepines ^[14]
  • Diazepam (off-label) ^[23]
  • Lorazepam (off-label) ^[23]
  • Clonazepam ^[23]

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. ^[14][23][24]

Counsel patients about potential adverse effects of vestibular suppressants (e.g., falls, cognitive dysfunction, drowsiness).

Vestibular rehabilitation ^[15][23][24]

• 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
• Indications
  • Vestibular neuritis
  • Meniere disease with chronic imbalance
  • BPPV
    • As adjunctive therapy to CRM
    • In refractory BPPV
    • If CRM is not possible
• 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., Cawthorne-Cooksey exercises, Brandt-Daroff exercises)

Etiology ^[3][5]

Focal neurological deficits are typically present in central causes of vertigo and vary depending on the location of the lesion and/or dysfunction. Neurological examination may show cranial nerve involvement, which is suggestive of brainstem involvement, and/or signs of cerebellar dysfunction.

Continuous, progressive vertigo followed by features of ↑ ICP may suggest life-threatening complications (e.g., cerebellar tonsillar herniation) of posterior fossa tumors (e.g., vestibular schwannoma, meningioma). Obtain immediate neuroimaging and consult neurosurgery. ^[4][27]

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 focal neurological deficits and/or abnormal HINTS testing:
  • Immediately start the diagnostic workup for stroke; initiate management simultaneously.
  • MRI is preferred to evaluate for posterior fossa ischemic stroke. ^[11]
  • If initial imaging shows no sign of hemorrhagic stroke or another neurological pathology, immediately initiate management of ischemic stroke.
  • See “Acute management checklist for ischemic stroke” or “Acute management checklist for intracerebral hemorrhage.”

Consider patients with acute vestibular syndrome and HINTS testing that suggests a central cause of vertigo to have a posterior fossa stroke until proven otherwise. ^[28]

This section lists common mimics of vertigo. For a comparison of different etiologies of vertigo, see “Causes of peripheral vertigo” and “Causes of central vertigo.”

Cardiac and neurological disorders

• Presyncope and syncope
  • Cardiac syncope (e.g., arrhythmogenic syncope)
  • Noncardiac syncope (e.g., orthostatic hypotension, neurocardiogenic syncope)
• Other neurological vertigo mimics
  • Focal seizures and epilepsy
  • Sensory ataxia
    • Reduced proprioception
    • Peripheral neuropathy (e.g., diabetic peripheral neuropathy, vitamin B₁₂ deficiency)
  • Neurodegenerative disorders (e.g., Alzheimer disease, Parkinson disease, Amyotrophic lateral sclerosis)

Other causes of dizziness

• Metabolic abnormalities
  • Electrolyte disturbances, e.g., hyponatremia, hyperkalemia, hypercalcemia
  • Hypoglycemia
• Persistent postural-perceptual dizziness
  • Chronic sensation of dizziness; lasting for ≥ 3 months without cochlear symptoms
  • Patients often suffer from anxiety and/or depressive disorders.
• Adverse effects: i.e., of medications and other substances (e.g., alcohol, recreational drug use) ^[29]
• Functional dizziness: e.g., anxiety disorders, panic disorder, somatic symptom and related disorders

Motion sickness ^[30][31]

• 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)
• Pathophysiology
  • 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
  • Gastrointestinal: nausea (most common) and vomiting
  • Autonomic: excessive sweating, pallor, yawning, drowsiness, and hypersalivation
  • Neurological: dizziness, headache, blurred vision, and spatial disorientation
• Diagnostics
  • No further workup is needed in patients reporting typical features and a history of motion sickness.
  • Urgent neuroimaging is indicated if symptoms, signs, and/or findings of otoneurological examination suggest a central cause (see “Peripheral vs. central vertigo” above).
• 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
    • Anticholinergic agents: scopolamine (most effective agent)
    • First-generation antihistamines: meclizine

Motion sickness can be prevented by suppressing vestibular pathways. Hence, anticholinergics and first-generation antihistamines are the first-line drugs for prevention.

The differential diagnoses listed here are not exhaustive.

Dizziness and vertigo in older adults ^[29][32]

• 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.
• Aging changes that increase the risk of dizziness and vertigo include:
  • Sensory deficits (e.g., polyneuropathy, impaired vision)
  • Polypharmacy
  • Sarcopenia
  • Increased prevalence of neurodegenerative conditions (e.g., Parkinson disease, Alzheimer disease, cerebellar ataxia)
  • Increased risk of ischemic stroke and long-term sequelae such as dizziness, vertigo, and balance disorders
• Management
  • Identify the underlying cause following the standard approach to vertigo. ^[29]
  • Reduce the risk of falls in elderly individuals 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.