Vertigo — Full Text

1ST STEP  —  When a patient comes to us for “dizziness,” before we go anywhere, it’s essential to determine which of two symptoms they’re experiencing:

• Vertigo
• Lightheadedness

These are entirely different & unrelated symptoms.  Their possible causes have nothing to do with each other.

Vertigo spins in just one single direction.  It may seem like the person spinning, the environment spinning, the person being thrust upon the environment, or the environment being thrust upon the person.  But whichever, everything keeps moving in the same direction.

Lightheadedness, on the other hand, is anything else.  It may be a feeling of wobbling, fuzziness, about to faint, unsteadiness, whatever.  All that matters is that it isn’t vertigo!

Some patients can’t explain sufficiently for me to decide, but I have to know!  Otherwise it’s impossible to come up with the differential diagnosis (list of possible causes).  I use two tricks:

1.  Demonstrate.  I spin around on my exam chair, or sweep circles in the air with my finger.  And I ask, “Are either you, or the room, spinning in one direction, like this?  Or, are things moving every which way (maybe like being tipsy or drunk)?”  Then I wobble myself a tiny bit in erratic directions.

People with true vertigo are invariably able to pinpoint the difference.  If the patient doesn’t quite understand what I’m aiming at, it’s probably not vertigo.

2.  If the patient thinks they actually had vertigo, that things were spinning, I ask, “Which direction?  Around and around to the right (clockwise), or to the left (counterclockwise)?”  If the patient stops to think hard, trying to decide, and I get the sense they know exactly what I’m talking about but just can’t remember which way they had spun, I’m happy.  It’s vertigo.

However, if they respond, “Huh?  No, not like that,” then I write in the chart, “Lightheaded, not vertigo” and go on from there. This topic addresses Vertigo.  For Lightheadedness, see link.

Vertigo is a symptom, not a disease.  It drives me nuts when a patient tells me they went to an ER for “dizziness,” and, “They told me I had Vertigo.” All they did was translate it into Latin!

Conditions that cause Vertigo are either (but not both together):

• Peripheral — problems of the inner ear (rarely external or middle ear)
• Central  —  problems in the brain

We maintain our balance by the Vestibular Apparatus, also called the Semicircular Canals, or Labyrinth, located in the inner ear (not the middle ear, where we get common ear infections: see Diagram of Ear Anatomy).  However, the brain’s Cerebellum controls coordination, and part of its Medulla also plays a role.  Most peripheral vertigo tends to get better on its own; central vertigo means bad things like strokes.

Virtually all vertigo is due to one of the two most common causes, both peripheral.  However, some rare ominous possibilities lurk; our job is to efficiently rule those out.

Causes of Vertigo

xxxxxPeripheral (Inner- or Middle-Ear)   • Benign Paroxysmal Positional Vertigo xxxx(BPPV) [this is the most common cause] • Acute Labyrinthitis [also fairly common] • Herpes Zoster • Meniere’s Disease • Labyrinthine Concussion • Perilymphatic Fistula • Semicircular Canal Dehiscence Syndrome • Otitis Media (middle ear infection) • Impacted Ear Wax

xxxxxxxxCentral (Brain)   • Stroke / TIA • Cervical Artery Dissection (tear) • Multiple Sclerosis (M.S.) • Migrainous Vertigo x x x x x

** Benign Paroxysmal Positional Vertigo (BPPV)  —  This is almost always our diagnosis! It literally means sudden bursts (“paroxysmal”) of vertigo due to head movement (“positional”), that aren’t serious (“benign”).  It’s far and away the most common cause of all, due to calcium flakes (“otoliths”) forming in the semicircular canals (labyrinth).  It’s more common >60 y.o., but occurs at any age.

Keys to Diagnosis:

• Occurs mainly with head motion, or change of head position
• Lasts <1 min. (usually much less, just seconds)
• Recurrent repetitive attacks, for an average of 2 weeks (may last months)
• No other neurological symptoms to suggest a stroke [see below] (nausea / vomiting may occur with anything that causes vertigo)

Physical exam is normal: both the Ear exam and Neurological exam.  But the Dix-Hallpike Test is often Positive.  It constitutes the start of the Epley Maneuver, which serves as treatment for BPPV.  Do see the links (both are the same).  It’s amazing to think how such a disturbing and frightening symptom can be cured by a few tilts of the head!

Dix-Hallpike finds BPPV 80% of the time.  If it’s negative, since BPPV is so common, we make the diagnosis anyway if “Keys to Diagnosis” above suggest it.  We recommend treatment with the full Epley Maneuver, to try to clear the calcium flake.

**  Acute Labyrinthitis  —  a.k.a. “Vestibular Neuritis” & other similar terms.  It’s presumably due to a virus, but nobody knows.  Here the vertigo is ongoing [as opposed to the momentary bursts of BPPV that only occur with head movement].  Physical exam (mainly a good neurological exam) is normal, except maybe for nystagmus (jerky eye movements).  Labyrinthitis will be our diagnosis, by history alone (with normal physical exam), if none of the other diseases in our list seem likely.  The main problem is ruling out Stroke (see right below).

Typical Course of Labyrinthitis: Severe vertigo for 24-48 hours, which then gets a lot better, though mild symptoms continue up to a few weeks, and subtle non-specific dizziness or imbalance may persist for months.  But this is no help, because we don’t want to sit on a stroke for 24-48 hours.

Both Stroke and Labyrinthitis begin abruptly.  Both cause nystagmus.  We must never diagnose Labyrinthitis if there is any suggestion of Stroke:

**  Stroke  —  A stroke in either the medulla or cerebellum of the brain can cause Vertigo.  But we don’t do a CT Scan or MRI on everyone.  We pursue this diagnosis based on a patient’s risks, other symptoms, and physical exam (see also Stroke as a Cause of Vertigo).

Stroke Risk Factors

• Age >60
• Hypertension
• Diabetes
• Certain auto-immune diseases (Lupus, etc.)

Stroke Symptoms (in the brain’s medulla)

• Double vision
• Slurred speech
• Hoarseness
• Trouble swallowing (even just saliva)

Stroke Symptoms (in the brain’s cerebellum)

• Poor coordination on one side, like repetitive tapping: done well with one hand, poorly with the other (leeway given to non-dominant side, e.g. left hand if they’re right-handed)

 Possible Torn Vertebral Artery (clot goes to the brain)

• Severe head or neck pain
• Recent trauma (may just be vigorous exercise, see link for examples)
• On One Side Only: tiny pupil, droopy eyelid, loss of sweating (maybe hard to determine)

Physical Examination

• Mainly a Neurological Exam, including special maneuvers most clinicians don’t know
• See Suspecting Strokes that Cause Vertigo

If an ER decides to do an “image” to look for Stroke, an MRI is much more accurate than a CT Scan.  But the CT is much easier to obtain quickly, so that’s often the first test ordered.  An image of the brain makes the diagnosis.  But a CT- or MR-Angiogram of both head and also the neck are necessary to find abnormalities that can cause a stroke (see CT scan link).

If there’s any chance of a Stroke, successful treatment is best performed in the first 3 hours.  It’s not done in just any ER, but needs to be done in a Stroke Center hospital, where expert neurologists make the diagnosis.  See below under Transient Ischemic Attack (TIA).

An elderly friend had Vertigo, and called 911.  The ambulance took her to a regular ER.  The doctors diagnosed a simple cause, and discharged her home; while leaving, she had a seizure, & later died.  I have no idea what exactly they did in the ER, but when it comes to Suspecting Strokes that Cause Vertigo, click the link for medical explanations of the initial history & physical exam, in case you or anybody wants to be sure they were examined well (many clinicians are not well-trained in this).

I spent a lot of time searching the NIH’s PubMed data base of published medical articles, for information on how frequently Stroke can cause vertigo all by itself, with no other symptom.  Seems to be around 1%, which is very reassuring.  So if there are no other stroke symptoms mentioned above, and a good basic neurological exam is normal, our patient with vertigo alone should be safe.

**  Transient Ischemic Attack (“TIA”) (of medulla or cerebellum)  —  Medical professionals explain this to patients as a “Mini-Stroke,” which isn’t exactly accurate.  “Ischemia” means lack  of blood circulation (carrying oxygen) to an organ.  A TIA means a clot began to cause a stroke and then dissolved, so no damage occurred in the brain (not even “mini-damage”).  The problem is that there’s a big chance of having a full-blown stroke in the future (even the near future).

Suppose a patient comes in having had an episode or more of recent vertigo, but now they’re fine.  Our exam will be entirely normal, and no special maneuvers will help us at all to make a diagnosis.  Who should we work-up?

• Patients with risk factors for Stroke (see above)
• Patients with a convincing history of Stroke Symptoms during the attack (see above)

What’s the work-up?  An MRI for signs of having actually had a stroke.  But more important, an MR-Angiogram or CT-Angiogram, to see if there’s narrowing of the vertebro-basilar arteries which feed the medulla and cerebellum.  Such a narrowing would 1) strongly suggest that recent symptoms were in fact TIAs; and 2) be worrisome for a future stroke.

We have to be sure that we order both an MRI of the brain to look for stroke scars, and also an angiogram of both head and neck to detect narrowed arteries.  But we don’t order a carotid artery ultrasound, which focuses on blood flow to the cerebrum, not to the medulla and cerebellum.  Many strokes happen in the cerebrum, but they don’t cause vertigo.

Unfortunately, there’s no surgery to prevent strokes from vetebro-basilar arteries, like for those parts of the brain fed by the carotid (a surgical endarterectomy).  All we can do is control risks (hypertension, etc.).

However, there is treatment for strokes in progress, which can stop them if given in the first 4-and-a-half hours (first 3 hours works better).  So if someone with known TIAs or strong risks for stroke gets sudden onset of persistent vertigo (lasting 5 minutes or more, not just brief bouts), they should call 911 and have the ambulance rush them to the nearest hospital with a stroke center [not a plain ER].

**  Multiple Sclerosis (MS)  —  Up to 50% of people with MS have vertigo, but rarely is it the first symptom.  MS is a clinical diagnosis, defined by dysfunction in at least two different parts of the central nervous system (brain & spinal cord):

• episodes are separated in time
• abnormalities resolve at least partially

So Vertigo would be one episode.  Assuming the patient is youngish (20-40), not stroke age, we ask about past episodes, lasting at least 24 hours, of other neurological symptoms typical for MS:

• Sensory symptoms in just one area of the body: numbness, tingling, coldness, etc.
• Lhermitte’s Sign: electric shock runs down body when bending the neck forward
• Visual disturbances, painful or not (optic neuritis)
• Double vision
• Weakness in just one part of the body, especially if there’s a disturbed gait
• Urinary Incontinence (exaggerated, not just drops) or Retention (bladder makes you want to pee, but you can’t)
• Uhthoff Phenomenon: above symptoms worsen with heat (fever, hot showers)

We do a focused physical exam, looking for left-over findings from any symptoms that might have been mentioned (e.g. loss of pinprick sensation wherever sensory symptoms may have been felt).  We’d certainly look into the eyes for Optic Atrophy (one optic disk is pale), and check the pupils by “swinging flashlight” for an Afferent Pupillary Defect (an essential test that many clinicians don’t remember to perform).

An MRI only confirms our clinical suspicion of MS; it’s not a final diagnosis.  We send suspected cases to a neurologist, since the diagnosis of MS has life-long implications, and treatment decisions early-on are very tricky.

**  Herpes Zoster Oticus  —  The chickenpox virus (Varicella-Zoster) remains hidden in a nerve, & may break out later in life as Shingles.  However, if it reactivates in the 8th Cranial Nerve, it causes “Ear Zoster” (a.k.a. Ramsay Hunt Syndrome).  Findings may include:

• Ear pain or headache (one-sided)
• Hearing loss, Ringing in the ear (one-sided)
• Facial droop (“Bell’s Palsy”)
• Blisters on the ear or in the ear canal — this clinches the diagnosis for sure, but they’re often absent.

Zoster usually occurs >60 y.o., which is stroke age.  If the vertigo is moderate-to-severe, I might prefer the E.R. manage the case, to rule out Stroke.  But if there are one-sided ear symptoms, with a normal neurological exam (or maybe just a “Bell’s Palsy”), and no other “Stroke” finding as noted above, the diagnosis is pretty safe.  [See Bell’s Palsy].

If the patient is young, we don’t worry much about stroke.  But anybody <50 with any kind of Zoster should get an HIV test (though it’s usually negative). Zoster is very common in HIV.

**  Other Ear Diseases  —  Sometimes common conditions like an Ear Infection, or lots of Impacted Ear Wax, can cause a vague sense of vertigo.  Treating the infection or removing the wax will determine for sure.

**  Meniere’s Disease  —  This condition of unknown cause may / may not be due to accumulation of fluid or ions in the inner ear.  But it’s not uncommon, can be disabling, and no true treatment exists.

Onset occurs between 20-40 years-old.  Attacks last 20 minutes to 24 hrs. (distinguishing it from BPPV and Labyrinthitis).  Diagnosis requires the following:

• Vertigo
• Hearing Loss (due to the inner ear nerve, not conditions of the outer or middle ear)
• Tinnitus (ringing in the ear) or Ear Fullness

The tinnitus is usually low-pitched.  The type of hearing loss can be determined by tuning forks, or even better, by humming (see Hearing Loss).  Ear symptoms assure us the condition is Peripheral, i.e. not a Stroke (though there is such a thing as a Labyrinth Stroke; extremely rare). 

We order formal audiometry (hearing tests), because hearing loss may be progressive and permanent.  Other conditions similar to the vertigo of Meniere’s don’t cause hearing loss.

The benign inner ear tumor Acoustic Neuroma causes hearing loss similar to Meniere’s, but there’s no vertigo, since growth is so slow that the brain learns to compensate.  There may, however, be a sense of imbalance or swaying.

“Cogan’s Syndrome,” is a very rare autoimmune condition with vertigo and eye inflammation.  If a Meniere’s patient gets bad eye pain, we’d consider it (I’ve never seen a case).

FOOTNOTE:  The above conditions comprise the main causes of Vertigo that we consider, especially the diagnosis of BPPV, & how to distinguish Labyrinthitis from Stroke.  The following discussion is meant to be complete, will undoubtedly be interesting, touches on some disabling diseases, but some conditions are probably a little (or lot) obscure.

Other causes of Vertigo

**  Labyrinthine Concussion  —  We’d diagnose this if symptoms begin at the moment of head trauma.  Instead of a disruption of microscopic nerve pathways in the brain (“Concussion”), here it’s the nerve receptors in the Labyrinth (aka “Vestibular Apparatus”).  I wouldn’t invoke the diagnosis if the vertigo began later on after the trauma.

**  Perilymphatic Fistula  —  This very-hard-to-diagnose leak of fluid from inner to middle ear can mimic many of the disorders in our table.  It’s caused by barotrauma (severe pressure change), including bomb blasts, airplane flights, & maybe even blowing your nose or suppressing a sneeze.  Symptoms range from acute vertigo, hearing loss, & tinnitus, to vague manifestations of those symptoms which come & go.  Its prevalence is debated, as is its diagnosis & treatment.

Moral: If a patient complains of vertigo that began after some form of barotrauma, we’d ask an ear specialist (ENT) to consider the possibility.

**  Superior Semicircular Canal Dehiscence Syndrome  —  This is due to a defect in the part of the skull which surrounds the delicate inner ear structure we need to control balance, namely the Semicircular Canals which are part of the Vestibular Apparatus (a.k.a. Labyrinth) (see Diagram — Anatomy of the Ear).  This condition is diagnostically remarkable for the strange symptoms it can provoke:

• Loud Noise induces vertigo & tremulous eyes (Tullio phenomenon)
• Pressure on the opening to the ear canal causes vertigo & tremulous eyes (Hennebert sign)
• Weird symptoms, like, “I hear my eyes moving;”
• Any strange perception that your own voice sounds distorted to you (echoes, etc.)
• Constant tinnitus (ringing in ear) which pulsates like a heartbeat

Any such suggestions would generate a referral to an Ear-Nose-Throat (ENT) specialist, who could confirm the diagnosis, and attempt a surgical repair.

**   Migrainous Vertigo  —  This is actually a common diagnosis, meaning “vertigo [that’s presumably] caused by the same [unproved] mechanisms that cause migraines.”  Personally, I’m not sure what to make of this.  The only consistent symptom is recurrent vertigo attacks of at least moderate severity.  Other aspects I’ve read about don’t seem convincing, for example:

• Duration can be seconds, minutes, hours, or days.  [how can this be useful?]
• May or may not have an associated headache.  [certainly not useful]
• Bright lights & loud noises are very irritating (photophobia & phonophobia),  [this may be somewhat convincing, since they help define migraine headaches]
• Aura (weird sensations occurring just before onset of attack)  [this is also convincing, but most migraine headaches actually lack them]
• Nausea / Vomiting  [any vertigo causes this].
• Suspect if there’s already a diagnosis of migraine headache  [but can’t a migraine sufferer have another cause of vertigo?]

If a known migraine patient has vertigo during typical attacks of headache, well, fine.  But I’d never venture this diagnosis for recurrent episodes of vertigo without first considering:

• Formal audiometry: if there’s hearing loss, it’s probably Meniere’s.
• Perilymphatic fistula might cause recurrent vertigo with hearing loss during the episodes, but maybe not at other times.  Worth an ENT referral.
• Multiple Sclerosis: warrants referral to a Neurologist, who can to decide about ordering complicated tests for M.S., and be the specialist who calls it “Migrainous Vertigo.”

I also read about a cause of vertigo called “Recurrent Vestibulopathy,” in which attacks of vertigo recur.  Unknown etiology.  No definite method of diagnosis.  To me, that’s just medical-speak for saying, “Well, you get recurrent attacks, we don’t know why, but it’s nothing serious, & you do get better.”  See “Migrainous Vertigo” above for proven diseases needing rule out.

And that’s it for Vertigo; hope it wasn’t too dizzying.

See also Vertigo for the clinician’s condensed thought-process when face-to-face with a patient.