Be sure you’re interested in Vertigo, not the “dizziness” we call Lightheadedness

  • Vertigo — room or person spinning or being thrust, in just one direction
  • Lightheadedness  —  a vague sense of being woozy, wobbly, unsteady, fuzzy, tipsy, etc., in any or all directions

The following represents the clinicianโ€™s condensed thought-process when face-to-face with a patient. For more in-depth discussion & explanations, see Vertigo — Full Text.

Causes of Vertigo

xxxxxPeripheral (Inner- or Middle-Ear)
โ€ข Benign Paroxysmal Positional Vertigo xxxx(BPPV) [this is the most common cause]
โ€ข Acute Labyrinthitis [also fairly common]
โ€ข Herpes Zoster
โ€ข Meniereโ€™s Disease
โ€ข Labyrinthine Concussion
โ€ข Perilymphatic Fistula
โ€ข Semicircular Canal Dehiscence Syndrome
โ€ข Otitis Media (middle ear infection)
โ€ข Impacted Ear Wax
xxxxxxxxCentral (Brain)
โ€ข Stroke / TIA
โ€ข Cervical Artery Dissection (tear)
โ€ข Multiple Sclerosis (M.S.)
โ€ข Migrainous Vertigo


1.ย  BPPV is far-&-away the most common & likely —ย  Symptoms occur with change of head position, last <1 min. (usually just seconds).ย  To be sure, we also:

  • Make sure no double vision, slurred speech, swallowing difficulty (may be a Stroke ?)
  • Examine Ears & Perform a Neurological Exam —ย  should be normal
  • Perform an Epley Maneuver (includes Dix-Hallpike) to confirm BPPV & serve as treatment
  • If negative, still likely BPPV. Can try in other direction. Have patient perform regularly at home
  • Still doesnโ€™t work?ย  If symptoms are truly <1 min duration, & only occur with head movement, we reassure patient theyโ€™ll recover, & encourage the Epley anyway.

2.ย  If Vertigo is new & acute, never happened before, is unrelated to head movement, & is ongoing non-stop through the day, we either:

  1. Diagnose Acute Labyrinthitis; OR
  2. Send to an E.R. to rule out Stroke or Cervical Artery Tear (in a neck artery)

We send a vertigo patient to the E.R. if any positives within the following table:

When We Worry that a Stroke may be causing Vertigo

xxxxxxxStroke Risk Factors  
โ€ข Age >60
โ€ข Hypertension
โ€ข Diabetes
โ€ข Some auto-immune diseases (Lupus, etc.)
โ€ข Certain heart diseases (atrial fibrillation, metal heart valves, etc.)

xxxxCertain Stroke Symptoms  
โ€ข Double vision
โ€ข Slurred speech
โ€ข Significant swallowing difficultyx
xxxxSuggestion of Cervical Artery Tear  
โ€ข Severe head or neck pain
โ€ข Recent trauma (including vigorous exercise; see link in Table)  

xxxSigns of Stroke on Physical Exam  
โ€ข Cranial nerve abnormalities
โ€ข Coordination abnormalities
โ€ข Special Maneuvers most Clinicians don’t know

See also Stroke as a Cause of Vertigo

We must send possible stroke to a Stroke Center Hospital, not just any E.R.

If the only positives above are the first three โ€œStroke Risk Factors,โ€ we may not send to an ER if we find any reason to diagnose Herpes Zoster Oticus (Shingles, but without blistering rash):

  • One-sided ear pain, hearing loss, tinnitus (ringing)
  • Facial droop (“Bell’s Palsy“)
  • Blisters on ear or in ear canal [often absent]

Of course, if there’s ear pain and we see an Ear Infection (Otitis Media), or Impacted Ear Wax, weโ€™ve got a diagnosis.

3.  Recurrent Vertigo (similar episodes have happened before), we consider:

** Meniereโ€™s Disease

  • Onset 20-40 y.o.
  • Attacks last 20 minutes to 24 hrs.
  • Diagnosis:  Vertigo + Neurologic Hearing Loss + Tinnitus
  • Requires formal hearing exam & referral to Ear specialist (ENT)

**  Labyrinthine Concussion  —  Vertigo episodes beginning right after head injury

  • If suspicious, we send to ENT for diagnosis & treatment

**  Perilymphatic Fistula  —  Vertigo caused by previous barotrauma (from pressure)

  • May be severe, or just come & go
  • Suspect if vertigo is provoked by straining, sneezing, coughing, even loud noises
  • If sounds possible by patient’s history, we send to ENT for diagnosis & treatment

** Superior Semicircular Canal Dehiscence Syndrome (SSCDS / SCDS) — probably rare

  • Loud Noise induces vertigo & tremulous eyes (Tullio phenomenon)
  • Pressure on opening to canal causes vertigo & tremulous eyes (Hennebert sign)
  • Weird symptoms, e.g. โ€œI hear my eyes moving;โ€ constant pulsating tinnitus (ringing in ear)

**  Multiple Sclerosis (MS)  —  We ask about previous typical MS symptoms, that lasted โ‰ฅ24 hrs.:

  • Tingling, numbness, loss of sensation
  • Electric shocks down body when bending neck (Lhermitteโ€™s Sign)
  • Visual disturbances, esp. Double vision
  • Weakness of just one part of body; disturbed gait
  • Urinary or Stool Incontinence (exaggerated occurrances, not just drops of urine or stains of stool), or Urinary Retention (bladder makes you want to pee, but you can’t)
  • Uhthoff Phenomenon: above symptoms worsen with heat (fever, hot showers)

We send to a Neurologist if suspicious symptoms, or Neurological abnormalities on exam, esp.:

  • Eyes (“optic atrophy”, “afferent pupillary defect“)
  • Complete loss of sensation by Pinprick Testing (can’t feel it) on areas of sensory symptoms
  • Decreased strength in just one part of body, on our physical exam

**  Migrainous Vertigo  —  Recurrent vertigo, moderate-severe.

  • Vertigo provoked by loud noises (phonophobia) & bright light (photophobia )
  • Vertigo w/ aura (various weird sensations just before the vertigo)
  • Vertigo in migraine sufferer
  • We’d let a Neurologist make this diagnosis & treat it
  • Uncertain if this condition truly exists, but it’s diagnosed fairly often

**  Stroke ???

  • maybe past episodes were TIAs, & today is the big one
  • See #2 above, and #4 below

4.  Vertigo now Resolved (maybe it was present when they called for appointment)

We consider the same diseases as in #1 and #3 above.  But we especially consider a Transient Ischemic Attack (TIA) and obtain an MRI (of brain) & MR-Angiogram (of head & neck) for anyone with:

  • History of Stroke Symptoms during the vertigo (see #2 above)
  • Maybe if significant Stroke Risk Factors (see #2 above)
  • But NOT if prominent Ear Symptoms along with the vertigo

If Vertigo recurs, and is not bursts of seconds-long attacks (BPPV), we send to a Neurologist.

See also Vertigo — Full Text for more in-depth explanations and discussions.

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