Epidemiology & Risk Factors

Peripheral causes (~80%):
- Benign Paroxysmal Positional Vertigo (BPPV): Most common; peak age 50–70; risk factors include head trauma, prior labyrinthitis/vestibular neuritis, prolonged bed rest.
- Ménière Disease: Age 20–50; risk factors include family Hx, autoimmune disease.
- Vestibular Neuritis/Labyrinthitis: Reactivation of HSV-1, preceding viral URI.
- Medication Toxicity: Aminoglycosides (e.g., gentamicin), loop diuretics, cisplatin.
Central causes (~20%):
- Cerebrovascular Disease (PICA/AICA stroke, TIA): HTN, DM2, smoking, hyperlipidemia, older age.
- Multiple Sclerosis (MS): Young females, demyelinating lesions of brainstem/vestibular pathways.
- Vestibular Migraine: Female predominance, personal/family Hx of migraine.
- Cerebellopontine Angle (CPA) Tumors: Vestibular schwannoma (associated w/ NF-2), meningioma.

Clinical Features

Symptom Clarification: True spinning/rotational sensation (differentiates from presyncope/lightheadedness and disequilibrium/ataxia).
Peripheral vs. Central Differentiation: c
- Peripheral Vertigo:
  - Onset: Sudden, severe, episodic.
  - Nystagmus: Horizontal or horizontal-torsional, unidirectional, fast phase beats away from affected ear; inhibited by visual fixation.
  - Associated Sxs: Nausea/vomiting, tinnitus, hearing loss (Ménière, labyrinthitis).
  - Auditory symptoms common; focal neurologic deficits absent.
- Central Vertigo:
  - Onset: Gradual or sudden (if vascular), constant, less severe nausea.
  - Nystagmus: Pure vertical (upbeat/downbeat), rotatory, or direction-changing; not inhibited by visual fixation.
  - Associated Sxs: Severe postural instability/gait ataxia (unable to walk/stand), focal neurologic deficits (dysarthria, dysphagia, diplopia, dysmetria, Horner syndrome).

Initial / Bedside Testing:
- Dix-Hallpike Maneuver: Diagnostic for BPPV (canalithiasis of posterior semicircular canal).
  - Positive: Latency of 2–20 sec followed by transient, fatiguable torsional/upbeating nystagmus toward lower ear.
- HINTS Exam (Head-Impulse, Nystagmus, Test of Skew) — differentiates central stroke from acute peripheral vestibulopathy:
  - Central Vertigo features: Normal Head Impulse Test (no corrective saccade), Direction-changing nystagmus, Skew deviation present (vertical ocular misalignment).
  - Peripheral Vertigo features: Abnormal Head Impulse Test (corrective saccade present), Unidirectional nystagmus, No skew deviation.
Key Labs: Electrolytes, glucose, CBC (routine workup to rule out systemic mimickers).
Imaging:
- MRI Brain with DWI / IAC protocol: Gold standard to evaluate posterior fossa stroke, MS plaques, or CPA tumors (vestibular schwannoma).
- Indicated if: Central signs/symptoms, abnormal HINTS exam, older pt with vascular risk factors, asymmetric SNHL, or lack of improvement.
- Note: CT head has very poor sensitivity for posterior fossa ischemic strokes.
Audiometry:
- Indicated in persistent/fluctuating hearing loss, tinnitus, or suspected Ménière disease (low-frequency SNHL).

BPPV:
- Diff: Recurrent brief episodes (< 1 min) triggered specifically by head position changes (e.g., rolling in bed, looking up); no hearing loss or tinnitus; fatiguable nystagmus on Dix-Hallpike.
Ménière Disease (Endolymphatic Hydrops):
- Diff: Triad of episodic vertigo (lasts 20 min to hours), fluctuating low-frequency SNHL, and tinnitus / aural fullness.
Vestibular Neuritis:
- Diff: Acute, prolonged, continuous vertigo (lasting days), severe nausea/vomiting, gait instability, post-viral; auditory function preserved.
Labyrinthitis:
- Diff: Identical presentation to vestibular neuritis (continuous vertigo for days) PLUS unilateral acute SNHL and tinnitus.
Vestibular Schwannoma (Acoustic Neuroma):
- Diff: Progressive unilateral SNHL, continuous mild imbalance/tinnitus, rarely acute spinning vertigo; loss of corneal reflex (CN V involvement).
Posterior Circulation Stroke (Wallenberg / Cerebellar Infarction):
- Diff: Acute sustained vertigo, severe ataxia, direction-changing/vertical nystagmus, focal neuro signs (dysphagia, hoarseness, ipsilateral Horner, contralateral pain/temp loss).
Vestibular Migraine:
- Diff: Episodic vertigo in pts with migraine history; associated with photophobia, phonophobia, visual aura (headache may or may not be present concurrently).

Acute Symptomatic Relief (All Etiologies):
- First-line: Vestibular suppressants (e.g., Meclizine, Diphenhydramine) + Antiemetics (e.g., Ondansetron, Promethazine).
- Second-line: Benzodiazepines (e.g., Diazepam, Lorazepam) for severe acute bouts.
- Constraint: Limit vestibular suppressants to < 48–72 hours to prevent inhibition of long-term central vestibular compensation.
Etiology-Specific Management:
- BPPV:
  - First-line: Epley maneuver (canalith repositioning procedure).
  - Refractory / Home care: Brandt-Daroff exercises.
- Vestibular Neuritis / Labyrinthitis:
  - First-line: Short course oral Corticosteroids (Prednisone taper) initiated early + vestibular rehabilitation therapy.
- Ménière Disease:
  - First-line / Preventive: Lifestyle modifications (low-salt diet < 2g/day, avoid caffeine, nicotine, alcohol).
  - Medical maintenance: Thiazide diuretics (e.g., HCTZ/triamterene).
  - Refractory: Intratympanic dexamethasone or gentamicin injections; surgical endolymphatic sac decompression.
- Vertebrobasilar / Cerebellar Ischemia:
  - Emergency stabilization, acute reperfusion (IV thrombolysis / endovascular thrombectomy if within time window), antiplatelet therapy (ASA + Clopidogrel), high-intensity statin, neuro ICU monitoring.

Falls, hip fractures, and traumatic head injury (high risk in elderly).
Permanent sensorineural hearing loss (Ménière disease, untreated labyrinthitis).
Progressive brainstem compression, tonsillar herniation, and obstructive hydrocephalus (large cerebellar infarction/edema or hemorrhage).
Persistent Postural-Perceptual Dizziness (PPPD; chronic functional dizziness following acute vestibular insult).

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