Overview
Acute Vertigo
1. Clinical Overview
Summary
Vertigo is illusion of rotation from vestibular asymmetry. Peripheral (BPPV, vestibular neuritis) vs Central (posterior circulation stroke). HINTS exam (Head Impulse, Nystagmus, Test of Skew) more sensitive than MRI in first 48h for stroke. INFARCT mnemonic: Impulse Negative, Fast phase Alternating, Refixation on Cover Test = CENTRAL.
Key Facts
- HINTS > MRI for early posterior circulation stroke
- BPPV: Brief (<60s), positional, Dix-Hallpike +, Epley curative
- Vestibular Neuritis: Days of vertigo, positive HIT = peripheral
- Limit suppressants: 48-72h only (delay compensation)
2. Epidemiology
Definition
Vertigo is the illusion of movement, typically rotational, either of oneself or the environment. It results from asymmetric input from the vestibular system and is distinct from other forms of dizziness such as presyncope, disequilibrium, or lightheadedness.
Types of Dizziness
| Type | Description | Common Causes |
|---|---|---|
| Vertigo | Illusion of rotation | Vestibular pathology |
| Presyncope | Feeling of impending faint | Cardiovascular (orthostatic, arrhythmia) |
| Disequilibrium | Unsteadiness, imbalance | Peripheral neuropathy, cerebellar disease |
| Lightheadedness | Non-specific, vague | Anxiety, hyperventilation, medication |
Peripheral vs Central Vertigo
| Feature | Peripheral | Central |
|---|---|---|
| Onset | Sudden | Variable |
| Intensity | Severe | Mild to moderate |
| Duration | Seconds to days | Persistent |
| Nystagmus | Unidirectional, horizontal/torsional | Any direction, vertical, direction-changing |
| Suppressed by fixation | Yes | No |
| Hearing loss/tinnitus | May be present | Usually absent |
| Neurological signs | Absent | May be present |
| Imbalance | Mild to moderate | Severe, unable to walk |
3. Pathophysiology
Vestibular Anatomy
Peripheral Vestibular System
- Semicircular canals (angular acceleration)
- Utricle and saccule (linear acceleration, gravity)
- Vestibular nerve (CN VIII)
Central Vestibular System
- Vestibular nuclei (brainstem)
- Cerebellum (vermis, flocculus)
- Cortical areas (parieto-insular cortex)
Mechanism of Vertigo
Normal Function
- Bilateral vestibular input maintains balance and spatial orientation
- Matched input from both sides = no vertigo
Pathological Asymmetry
- Unilateral decrease or increase in vestibular input
- Brain perceives asymmetry as rotation
- Nystagmus away from affected side (in peripheral lesions)
Vestibular Compensation
- Central adaptation to vestibular lesion
- Occurs over days to weeks
- Vestibular suppressants may delay compensation
- Early mobilization promotes compensation
4. Clinical Presentation
Common Peripheral Causes
Benign Paroxysmal Positional Vertigo (BPPV)
Vestibular Neuritis
Labyrinthitis
Meniere's Disease
Central Causes
Posterior Circulation Stroke (Most Critical)
Other Central Causes
| Condition | Features |
|---|---|
| Multiple sclerosis | Young patient, prior neurological episodes |
| Brainstem tumor | Gradual onset, progressive |
| Vestibular migraine | Migraine history, triggers |
| Medication toxicity | Aminoglycosides, anticonvulsants |
HINTS Examination
Head Impulse test, Nystagmus, Test of Skew
| Component | Peripheral Finding | Central Finding |
|---|---|---|
| Head Impulse | Positive (corrective saccade) | Negative (normal VOR) |
| Nystagmus | Unidirectional, horizontal | Direction-changing, vertical, purely torsional |
| Test of Skew | Negative | Positive (vertical deviation on cover) |
Mnemonic: INFARCT
If any of these are present → concerning for central lesion
Symptom Characterization
Key History Questions
- True vertigo or other dizziness type?
- Episodic or constant?
- Duration of episodes?
- Positional triggers?
- Associated hearing loss, tinnitus?
- Neurological symptoms (weakness, numbness, diplopia)?
- Headache?
- Vascular risk factors?
Most common cause of vertigo
Common presentation.
Brief episodes (<60 seconds) triggered by head position
Common presentation.
Otoconia (ear crystals) displaced into semicircular canal
Common presentation.
Positive Dix-Hallpike test
Common presentation.
Treatment
Canalith repositioning maneuvers
5. Clinical Examination
Red Flags (Life-Threatening)
High-Risk Features for Central Cause
| Red Flag | Concern | Action |
|---|---|---|
| New headache | Stroke, hemorrhage | Urgent neuroimaging |
| Neurological deficits | Brainstem/cerebellar stroke | Stroke protocol |
| Vertical nystagmus | Central lesion | Neurology consultation |
| Direction-changing nystagmus | Central lesion | MRI |
| Negative head impulse test | Central lesion (in acute vertigo) | MRI, stroke evaluation |
| Skew deviation | Brainstem lesion | Stroke evaluation |
| Severe imbalance (unable to sit/walk) | Cerebellar involvement | Neurology consultation |
| Vascular risk factors | Stroke | Lower threshold for imaging |
| Neck pain | Vertebral dissection | CT/MR angiography |
Posterior Circulation Stroke Risk Factors
ABCD2 +
- Age >60
- Blood pressure elevation
- Clinical features (unilateral weakness, speech)
- Duration
- Diabetes
Additional Stroke Risk Factors
- Atrial fibrillation
- Prior stroke/TIA
- Smoking
- Hyperlipidemia
- Recent trauma (dissection)
Differential Diagnosis
By Timing and Triggers
Episodic, Position-Triggered (Seconds)
- BPPV (most common)
- Orthostatic hypotension
Episodic, Spontaneous (Minutes to Hours)
- Meniere's disease
- Vestibular migraine
- TIA (posterior circulation)
- Panic attack
Constant (Days)
- Vestibular neuritis
- Labyrinthitis
- Stroke
- Multiple sclerosis
Dangerous Mimics
| Condition | Distinguishing Features |
|---|---|
| Cerebellar stroke | Unable to walk, HINTS concerning, risk factors |
| Brainstem stroke | Cranial nerve findings, crossed signs |
| Vertebral dissection | Neck pain/trauma, younger patient |
| Intracranial hemorrhage | Severe headache, altered consciousness |
| Bacterial labyrinthitis | Hearing loss, prior otitis media |
| Perilymphatic fistula | Post-trauma/surgery, hearing loss |
6. Investigations
Diagnostic Approach
Clinical Evaluation
Step 1: Clarify Dizziness Type
- Is it truly vertigo (rotational sensation)?
- Distinguish from presyncope, disequilibrium, lightheadedness
Step 2: Determine Timing/Triggers
- Brief recurrent vs prolonged continuous
- Positional vs spontaneous
Step 3: Perform HINTS Examination
- For continuous vertigo with nystagmus
- Most valuable in acute vestibular syndrome
Step 4: Complete Neuro Examination
- Cranial nerves (especially CN V, VII, VIII)
- Cerebellar testing (finger-nose, heel-shin, gait)
- Limb strength and sensation
- Romberg test
Bedside Tests
Dix-Hallpike Test (for BPPV)
Technique:
1. Patient seated, head turned 45° to one side
2. Rapidly lie patient down with head extended 20° off table
3. Watch for nystagmus (latency 2-5 seconds, fatigable)
4. Positive = torsional/upbeating nystagmus toward affected ear
5. Repeat on other side
Interpretation:
- Positive + correct nystagmus pattern = BPPV
- If positive, treat with Epley maneuver
Head Impulse Test
Technique:
1. Patient fixates on examiner's nose
2. Rapidly rotate head ~15° then return
3. Observe for corrective saccade
Interpretation:
- Corrective saccade = peripheral lesion (positive test)
- No saccade = normal VOR or CENTRAL lesion (dangerous!)
Cover-Uncover Test (Skew Deviation)
Technique:
1. Patient fixates on target
2. Cover one eye for 2 seconds
3. Uncover and watch for vertical correction
Interpretation:
- Vertical correction = skew deviation = CENTRAL cause
Laboratory Studies
| Test | Purpose |
|---|---|
| Glucose | Hypoglycemia |
| ECG | Arrhythmia causing presyncope |
| Electrolytes | Metabolic derangement |
| CBC | Anemia |
| Drug levels | Medication toxicity |
Imaging
When to Image
| Indication | Modality |
|---|---|
| Concerning HINTS exam | MRI with DWI (preferred) |
| Neurological deficits | MRI brain |
| Possible stroke | MRI DWI (CT less sensitive for posterior fossa) |
| Neck pain, trauma | CT/MR angiography (vertebral dissection) |
| BPPV with typical features | No imaging needed |
| Vestibular neuritis with positive HIT | Usually no imaging needed |
Important Note on MRI
- DWI-MRI may be FALSE NEGATIVE in first 24-48 hours for posterior fossa stroke
- HINTS exam is MORE SENSITIVE than MRI in first 48 hours
- If clinical suspicion high, repeat imaging or admit for observation
7. Management
BPPV Management
Epley Maneuver (for Posterior Canal BPPV)
Steps:
1. Start seated, head turned 45° toward affected ear
2. Lie back (Dix-Hallpike position) - wait 30-60 seconds
3. Turn head 90° to opposite side - wait 30-60 seconds
4. Roll onto that side, nose down - wait 30-60 seconds
5. Slowly sit up
Success rate: 70-80% after single treatment
May be repeated if unsuccessful
Log Roll Maneuver (for Horizontal Canal BPPV)
- Identified by horizontal nystagmus on roll test
- Sequential 90° rotations toward unaffected ear
Vestibular Neuritis/Labyrinthitis
Acute Management
| Medication | Dose | Notes |
|---|---|---|
| Meclizine | 25-50mg PO q6h PRN | Vestibular suppressant |
| Dimenhydrinate | 50mg PO/IV q6h | Alternative to meclizine |
| Ondansetron | 4-8mg IV/PO | For nausea |
| Diazepam | 2-5mg PO q8h | Short-term for severe symptoms |
| Promethazine | 12.5-25mg IV/IM | Antiemetic |
Important: Limit vestibular suppressants to 48-72 hours (impair compensation)
Corticosteroids
- Consider methylprednisolone taper for vestibular neuritis
- Most beneficial if started within 72 hours
- 100mg tapered over 3 weeks (evidence modest)
Vestibular Rehabilitation
- Early referral improves outcomes
- Promotes central compensation
- Exercises to provoke symptoms (habituation)
Meniere's Disease
Acute Attack
- Vestibular suppressants (as above)
- Antiemetics
- Reassurance
Prevention
- Low-sodium diet (<2g/day)
- Diuretics (thiazides)
- Avoidance of caffeine, alcohol
- Betahistine (not available in US)
Central Vertigo (Stroke)
If Central Cause Suspected
1. NIL PER OS (aspiration risk)
2. IV access, fluids
3. Continuous monitoring
4. Neurology/stroke team consultation
5. MRI brain with DWI
6. Consider thrombolysis if within window
7. Admit for observation, repeat imaging if initially negative
8. Complications
Disposition
Admission Criteria
Admit for:
- Suspected or confirmed central cause (stroke, MS flare)
- Unable to tolerate oral intake (intractable vomiting)
- Severe symptoms requiring IV medications
- Unable to ambulate safely
- Uncertain diagnosis with concerning features
- Need for neurology consultation/workup
ICU/Stroke Unit:
- Confirmed posterior circulation stroke
- Cerebellar stroke at risk for herniation
- Hemodynamic instability
Discharge Criteria
Safe for Discharge (Peripheral Vertigo)
- Clear peripheral diagnosis (BPPV with positive Dix-Hallpike, vestibular neuritis with positive HIT)
- Symptoms controlled with oral medications
- Able to ambulate safely (with assistance if needed)
- Able to tolerate oral intake
- Reliable follow-up arranged
- No red flags present
Follow-up Recommendations
| Condition | Follow-up |
|---|---|
| BPPV | Audiology/ENT if recurrent; usually self-limited |
| Vestibular neuritis | PCP in 1-2 weeks; vestibular PT referral |
| Meniere's disease | ENT specialist |
| Uncertain diagnosis | Neurology referral |
| Central cause | Stroke workup, neurology follow-up |
11. Patient/Layperson Explanation
Understanding Vertigo
- Vertigo is a symptom, not a disease
- Most causes are benign but can be debilitating
- Recovery from vestibular neuritis takes weeks
- BPPV can often be cured with simple maneuvers
Activity Guidelines
BPPV
- Sleep with head elevated for 1-2 nights after Epley
- Avoid sleeping on affected side for 1-2 days
- Avoid rapid head movements
Vestibular Neuritis
- Early movement promotes recovery
- Avoid prolonged bed rest
- Balance exercises as tolerated
Warning Signs to Return
- New headache or worsening headache
- Weakness or numbness in limbs
- Difficulty speaking or swallowing
- Double vision
- Hearing loss
- Unable to walk due to imbalance
- Symptoms persistently worsening
Medication Instructions
- Vestibular suppressants cause drowsiness
- Do not drive while taking meclizine or diazepam
- Use medications only as needed for severe symptoms
- Do not take for more than 2-3 days (delays recovery)
9. Prognosis & Outcomes
Special Populations
Elderly Patients
- Higher risk for stroke (lower threshold for imaging)
- More likely to have multifactorial dizziness
- Consider polypharmacy as contributor
- Higher fall risk - ensure safe disposition
Patients with Vascular Risk Factors
- Even "typical" BPPV may warrant imaging
- Lower threshold for neurology consultation
- Consider posterior circulation TIA registry
Pediatric Vertigo
- Less common in children
- Consider benign paroxysmal vertigo of childhood
- Migraine-associated vertigo more common
- Otitis media-related labyrinthitis
Pregnancy
- BPPV may be more common
- Avoid vestibular suppressants if possible
- Safe medications: Meclizine (Category B)
- Avoid benzodiazepines
10. Evidence & Guidelines
Quality Metrics
Performance Indicators
| Metric | Target |
|---|---|
| HINTS examination performed in acute vestibular syndrome | >0% |
| Documented assessment of neurological signs | 100% |
| Appropriate imaging for central concern | >5% |
| Stroke consultation for central findings | 100% |
| Epley maneuver performed for BPPV | >0% |
| Fall risk assessment | 100% |
Documentation Requirements
- Type of dizziness (vertigo vs other)
- Timing and triggers
- HINTS examination findings (if applicable)
- Dix-Hallpike result (if BPPV suspected)
- Neurological examination
- Assessment of gait and fall risk
- Risk factors for stroke
- Rationale for imaging or observation
- Treatment provided and response
- Clear follow-up instructions
Key Clinical Pearls
Diagnostic Pearls
- HINTS > MRI for early posterior circulation stroke (in first 48h)
- Negative head impulse is dangerous in acute vestibular syndrome
- Vertical nystagmus is always central - never peripheral
- BPPV is brief (<60 seconds) - prolonged vertigo is not BPPV
- Can walk = more likely peripheral - unable to sit = concerning
Treatment Pearls
- Limit vestibular suppressants to 48-72 hours
- Epley is curative for posterior canal BPPV
- Nothing beats good clinical exam - imaging is adjunct
- Early mobilization promotes vestibular compensation
- Refer for vestibular PT - improves outcomes
Disposition Pearls
- When in doubt, admit for observation
- HINTS-positive for peripheral can be discharged with follow-up
- Risk factors matter - lower imaging threshold in older patients
- Clear return precautions are essential
- Close follow-up for unresolved or recurrent symptoms
12. References
- Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke. 2009;40(11):3504-10.
- Kerber KA, Newman-Toker DE. Misdiagnosing Dizzy Patients: Common Pitfalls in Clinical Practice. Neurol Clin. 2015;33(3):565-575.
- von Brevern M, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. J Vestib Res. 2015;25(3-4):105-17.
- Strupp M, Magnusson M. Acute Unilateral Vestibulopathy. Neurol Clin. 2015;33(3):669-685.
- Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47.
- Newman-Toker DE, et al. Spectrum of dizziness visits to US emergency departments. Mayo Clin Proc. 2008;83(7):765-75.
Version History
| Version | Date | Changes |
|---|---|---|
| 1.0 | 2025-01-15 | Initial comprehensive version with 14-section template |