Vertigo – Any illusion of movement (spinning, rocking, sense of falling or being pushed or pulled) which is distinct from dysequlibrium (loss of balance from visual disturbance, sensory or cerebellar ataxia, or extrapyramidal syndrome) and presyncope (feeling of impending loss of consciousness, faintness, lightheadedness, often associated with tunnel vision, diaphoresis, palpitations, etc.).

Differential Diagnosis

Peripheral vertigo (more common)

• BPPV (brief [seconds – 2 minutes] episodes of vertigo with head turning)
• Vestibular neuritis (preceding viral syndrome leading to vertigo, n/v, gait instability; if hearing loss present, vestibular labyrinthitis)
• Meniere’s disease (periodic vertigo, low frequency hearing loss, tinnitus; all three features may not be present simultaneously)
• Ototoxic or cochleotoxic agents (aminoglycosides, aspirin, furosemide, etc.)
• Vestibular schwannoma (slowly progressive vertigo and hearing loss)

Central vertigo

• Vertebrobasilar ischemia/TIA
• Migraine
• Multiple sclerosis
• Posterior fossa hemorrhage
• Drug toxicity (phenytoin, carbamazepine, EtOH)

Initial Evaluation

History

• Have the patient describe their symptoms; are they “dizzy” now? If not, how do they know when they are “dizzy”?
• Have you had this before?
• Is the vertiginous component constant or intermittent?
• If intermittent, how long does the vertiginous component last? 
  • Seconds – 2 minutes: BPPV
  • Several minutes: TIA, migraine
  • Hours: migraine, Meniere’s disease, TIA/stroke
  • Days to weeks: vestibular neuritis, migraine, stroke, brainstem/cerebellar lesions, drug toxicity
• Is the vertigo provoked or random?
  • Triggers:
    • Rolling in bed, certain head positions, looking up (BPPV)
    • Stress, dehydration, skipped meals, moving objects (migraine)
• Are there any associated symptoms?
  • Hearing loss, aural fullness, ear pain, tinnitus, nausea/vomiting, dysarthria, diplopia, dysphagia, ataxia, hoarseness, weakness, numbness, loss of consciousness, headache, photo/phonophobia, neck pain, fever
• Look for risk factors for cerebrovascular disease (age, diabetes, smoking, hyperlipidemia, hypertension, atrial fibrillation, known vascular disease, etc.)

Exam: perform complete neurologic exam, including HINTS exam:

• Head impulse test (head thrust test)
  • Turning the head quickly stimulates vestibular function on the side in which the head is turned. IF there is a loss of vestibular function on one side, the eyes will move with the head and the patient will initiate a voluntary catch-up saccade to look back at the target
• Nystagmus
  • Nystagmus is named for direction of fast phase
  • Unidirectional nystagmus results in fast phase toward one direction in either direction of gaze (e.g. left-beating nystagmus has fast phase to the left when looking to the right or to the left)
  • Bidirectional nystagmus changes direction of fast phase with change in direction of gaze
• Test of skew
  • Ask the patient to fixate on a central target (examiner’s nose). Alternate occluding each eye with your hand. Observe movements of the eye that was just occluded; normally, eyes should remain motionless. Abnormal if vertical corrective saccade (re-fixation on target) after removal of cover. Vertical skew deviation predicts brainstem involvement 
• Overall, positive head impulse test, unidirectional nystagmus, and/or negative test of skew are suggestive of peripheral etiology; conversely, negative head impulse test, bidirectional/vertical nystagmus, and/or positive test of skew are suggestive of central etiology
• Look for brain stem signs on exam which suggest vertebrobasilar ischemia (cranial neuropathies, ataxia), and focal sensory and motor defects. Note that, although rare, isolated infarction and/or hemorrhage of the inferior cerebellum can cause vertigo, nystagmus, and postural instability with little else

Imaging

If you are concerned about central vertigo (especially vertebrobasilar ischemia), perform CT brain without contrast in acute setting to rule out hemorrhage; if unremarkable, order MRI brain w/o contrast.

When in doubt, consult neurology.

Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med 2003;348:1027-1032.

Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med 1998;339:680-685.