Selected Causes of Dizziness and Vertigo

Peripheral vestibular system disorders^a,b

Benign paroxysmal positional vertigo (BPPV)

Severe, brief (< 2 minute) spinning produced by moving head in a specific direction

Nystagmus that has a latency of 0 to 30 seconds, is fatigable, and is torsional, beating toward the undermost ear

Frenzel goggles often needed to prevent visual fixation and reveal nystagmus

Hearing and neurologic examination normal

Dix-Hallpike maneuver to assess characteristic positional nystagmus

Meniere disease

Spinning sensation, most times with nausea and vomiting, lasting 20 minutes to 12 hours

Recurrent episodes of unilateral tinnitus, hearing loss, ear fullness during episodes of vertigo

Audiometry

Gadolinium-enhanced MRI to exclude other causes

Vestibular neuronitis (viral cause suspected)

Sudden, incapacitating, severe vertigo with no hearing loss or other findings

Lasts up to 1 week, with gradual lessening of symptoms

Positional vertigo may result

Sometimes history and physical examination alone (if early, spontaneous nystagmus can be observed; if examination done days later, weakness observed with head impulse test)

Sometimes gadolinium-enhanced MRI

Positional vertigo in neuronitis can be differentiated from BPPV by a Dix-Hallpike maneuver

Labyrinthitis (viral or bacterial)

Hearing loss, tinnitus

Audiometry

Temporal bone CT if purulent infection suspected

Gadolinium-enhanced MRI if unilateral hearing loss and tinnitus

Otitis media (acute or chronic, sometimes with cholesteatoma)

Ear pain, abnormal ear examination, including discharge if chronic otitis

History of infection

Audiometry

With cholesteatoma, CT to exclude semicircular canal fistula formation

Trauma (eg, tympanic membrane rupture, labyrinthine contusion, perilymphatic fistula, temporal bone fracture, postconcussion)

Trauma obvious on history

Other findings depending on location and extent of damage

Sometimes history and physical examination alone

Sometimes CT

Vestibular schwannoma or meningioma of the posterior fossa or internal auditory canal

Slowly progressive unilateral hearing loss, tinnitus, dizziness, dysequilibrium

Rarely, facial numbness, weakness, or both

Audiometry

Gadolinium-enhanced MRI if significant hearing asymmetry or unilateral tinnitus

Ototoxic medications^c

Treatment with aminoglycosides (eg, gentamycin) recently instituted, usually with bilateral hearing loss and vestibular loss

Audiometry

Sometimes vestibular evaluation with electronystagmography and rotary chair tests

Herpes zoster oticus

Also affects geniculate ganglion, so facial weakness and taste loss on the side of the tongue of the facial weakness often manifest along with hearing loss

Vertigo possible but not typical

Vesicles present on pinna and in ear canal

History and physical examination alone

Chronic motion sickness

Persistent symptoms after acute motion sickness

History and physical examination alone

Central vestibular system disorders^d

Brain stem hemorrhage or infarction

Sudden onset

Involvement of cochlear artery possibly causing hearing loss and tinnitus

Immediate imaging (gadolinium-enhanced MRI if available, otherwise CT)

Cerebellar hemorrhage or infarction

Sudden onset, with ataxia and other cerebellar findings, often headache

Deteriorates rapidly

Immediate imaging (gadolinium-enhanced MRI if available, otherwise CT)

Vestibular migraine

Episodic, recurrent vertigo or dizziness, sometimes with unilateral auditory symptoms such as ear fullness and pressure, may have tinnitus that is usually bilateral

Need to have prior history of migraine headaches, with ≥ 1 migraine features^e in at least 50% of dizziness/vertigo episodes to diagnose

In those without personal history of migraine headaches, family history of migraines is highly suggestive and can make the diagnosis of "probable" vestibular migraine

Usually history and physical examination but with brain imaging as needed to exclude other causes

Sometimes trial of migraine prophylaxis

Multiple sclerosis

Varied CNS motor and sensory deficits, with remissions and recurring exacerbations

Gadolinium-enhanced MRI of brain and spine

Vertebral artery dissection

Often head and neck pain and acute, severe imbalance or ataxia

Magnetic resonance angiography

Vertebrobasilar insufficiency

Intermittent brief episodes, sometimes with drop attacks or extreme imbalance episodes, visual disturbance, confusion

Magnetic resonance angiography

Global disturbance of CNS function^f

Anemia (numerous causes)

Pallor, weakness, sometimes heme-positive stool

Complete blood count

CNS-active medications^g (not ototoxic)

Medication recently instituted or dose increased; multiple medications, particularly in an older patient

Symptoms unrelated to movement or position

Sometimes history and physical examination alone

Sometimes medications levels (certain antiseizure medications)

Sometimes trial of withdrawal

Hypoglycemia (usually caused by medications for diabetes)

Recent dose increase

Sometimes sweating

Fingerstick glucose test (during symptoms if possible)

Hypotension (caused by cardiac disorders, antihypertensives, blood loss, dehydration, or orthostatic hypotension syndromes including postural orthostatic tachycardia syndrome and other dysautonomias)

Symptoms on rising from seated or supine, sometimes with vagal stimulation (eg, urination) but not with head motion or while recumbent

Manifestation possibly dominated by cause (eg, blood loss, diarrhea)

Orthostatic vital signs, sometimes with tilt table test, ECG

Hypoxemia (numerous causes)

Tachypnea

Often history of lung disease

Pulse oximetry

Chest radiograph

Other causes^f

Persistent perceptual postural dizziness (PPPD)

Chronic non-spinning dizziness (an internal sensation of swaying) persisting for > 3 months, on most days

Symptoms worse when standing still, especially while in line, with active (head movement) or passive motion (eg, driving past street lights at night, cars passing while the patient is stopped) or with visual stimulation (eg,, when entering a grocery store)

Often precipitated by other acute conditions such as BPPV or vestibular migraine

Can be a manifestation of anxiety disorder

History and physical examination alone

Pregnancy

May be unrecognized

Pregnancy test

Psychiatric (eg, panic attack, hyperventilation syndrome, anxiety, depression)

Symptoms chronic, brief, recurrent

Unrelated to movement or position but may occur with stress or upset

Neurologic and otologic examinations normal

Initially, patient may be diagnosed with peripheral vestibular dysfunction and fail to respond to appropriate management

History and physical examination alone

Syphilis

Chronic symptoms with bilateral hearing loss, fluctuating, with episodic vertigo

Audiometry

Syphilis serology

Thyroid disorders

Weight change

Heat or cold intolerance

Thyroid function testing

Uncompensated peripheral vestibular weakness

Dysequilibrium

Visual blurring (an internal sensation of swaying) with head turning

Can follow episodes of vestibular neuronitis, migraine with vertigo, Meniere disease or after head trauma or inner ear surgery

Vestibular testing