Vertigo

Differentials

Most Common

• BPPV (Benign Paroxysmal Positional Vertigo)

• Vestibular Neuritis

• Vestibular Migraine

Peripheral Causes

• BPPV: Brief episodes (seconds–minutes), often triggered by certain head positions.

• Vestibular Neuritis/Labyrinthitis: Involves the vestibular nerve ± cochlea (labyrinthitis if hearing loss is present). Typically follows viral infections.

• Ménière’s Disease: Overdiagnosed. Characterised by recurrent, longer episodes of vertigo (often hours), with tinnitus, hearing loss, and ear fullness.

• Chronic Otitis Media, Ramsay Hunt (herpes zoster oticus)

• Acoustic Neuroma (vestibular schwannoma): Usually progressive hearing loss, slower onset.

Central Causes

• TIA, Cerebellar Stroke, Vertebrobasilar Insufficiency

• Vestibular Migraine (central cause; can mimic peripheral presentations)

History

• Nausea/Vomiting: Common in acute severe vertigo.

• Recent Viral Illness: Suggests vestibular neuritis.

• Hearing Loss, Tinnitus, Ear Fullness: Consider Ménière’s, labyrinthitis, acoustic neuroma.

• Otalgia, Otorrhoea, Fever: Ear infections.

• Vertigo Duration:

  • Seconds–minutes: BPPV

  • Hours: Ménière’s, migraine

  • Persistent days: Vestibular neuritis, labyrinthitis

• Weakness, Sensory Loss, Dysarthria, Vision Loss: Suggest possible stroke or central lesion.

• Headache: May indicate migraine or intracranial pathology.

• HSV-1 Reactivation: Potential cause of vestibular neuritis.

• Family History: Ménière’s can have familial patterns (less common).

• Vesicular Rash: Possible Ramsay Hunt syndrome (HZ oticus).

• Ataxia: More pronounced in central lesions or severe peripheral involvement.

• BPPV: Typically triggered by position changes (rolling over in bed, looking up).

Examination

• Heart Rate, Rhythm: Rule out arrhythmias.

• Blood Pressure: Orthostatic hypotension → drop in systolic >20 mmHg or diastolic >10 mmHg may cause dizziness/syncope.

• Ear Inspection: Vesicles (Ramsay Hunt), cholesteatoma.

• Hearing Assessment: Simple tuning fork tests or formal audiometry if needed.

• Gait (heel-toe), Balance (Romberg), Coordination (finger-nose, dysdiadochokinesia).

• Nystagmus:

  • Peripheral: Horizontal/rotatory, unidirectional, can lessen with gaze fixation. In BPPV (Dix-Hallpike), vertical + torsional nystagmus may appear transiently.

  • Central: May be purely vertical, bidirectional, or persistent with gaze fixation.

• Dix-Hallpike Test: Diagnostic for BPPV when positive.

• HINTS Exam: Used to differentiate vestibular neuritis from stroke (accurate if performed by trained examiners).

Diagnosis

• MRI (Gadolinium-enhanced) if acoustic neuroma suspected or central signs.

• Imaging indicated if headache, stroke risk factors, focal neurological deficits, or suspicion of central lesion.

• Blood Glucose check: Hypoglycaemia can present with dizziness.

• Consider thyroid function, electrolytes if relevant.

Management

• BPPV: Epley or other canalith repositioning manoeuvres (first-line).

• Ménière’s Disease: Low-salt diet, possibly betahistine (evidence variable), diuretics in some cases.

• Vestibular Rehab: Useful for persistent/chronic vestibular dysfunction (physiotherapy approach).

• Suspected Stroke/TIA: Urgent neuroimaging (MRI brain) and neurological referral.

Treatment of Vestibular Symptoms

• Prochlorperazine (Stemetil) 10 mg TDS × 2 days, or

• Ondansetron 8 mg TDS × 2 days

• Avoid long-term use (>48 hrs) to prevent delaying central compensation.

Treatment of Vestibular Neuritis

• Prednisolone 1 mg/kg (max ~75 mg) OD for 5 days.

• Antivirals (e.g., valaciclovir) not routinely recommended unless strong suspicion of herpes zoster involvement.

Notes

• If vomiting → IM prochlorperazine/ondansetron.

• Vestibular Neuritis: Typically acute severe vertigo, ataxia, lasts days.

• Ménière’s: Recurrent episodic vertigo (minutes–hours) with tinnitus, hearing loss, ear fullness.

• Labyrinthitis/BPPV: Worse with head movement.

• Vestibular Migraine: Central-type nystagmus, migraine history, headache features possible.