Diagnostic Approach to Vertigo

Introduction to Vertigo Diagnosis

The American Academy of Otolaryngology-Head and Neck Surgery recommends confirming true vertigo and distinguishing peripheral from central causes through targeted history and physical examination, with the Dix-Hallpike maneuver being essential for diagnosing benign paroxysmal positional vertigo (BPPV) 1, 2

Patients should be asked to describe the sensation specifically to distinguish true vertigo, a false sensation of self-motion or spinning of visual surroundings, from vague "dizziness," lightheadedness, or presyncope 3
Loss of consciousness never occurs with vertigo and suggests a different diagnosis 3

Triggered episodic vertigo, brief episodes provoked by head position changes, suggests BPPV 1, 2
Spontaneous episodic vertigo, attacks lasting minutes to hours without positional triggers, suggests Ménière's disease or vestibular migraine 3
Acute vestibular syndrome, continuous vertigo lasting hours to days, suggests vestibular neuritis or stroke 3, 4

Peripheral vertigo nystagmus is characterized by a horizontal with rotatory (torsional) component, unidirectional, suppressed by visual fixation, and fatigable with repeated testing 4
Central vertigo nystagmus is characterized by a pure vertical without torsional component, direction-changing without head position changes, and not suppressed by visual fixation 4, 5

The Dix-Hallpike maneuver is performed by bringing the patient from an upright to a supine position with the head turned 45 degrees to one side and neck extended 20 degrees 1, 2
Diagnostic criteria for posterior canal BPPV include a history of repeated episodes of vertigo with head position changes, a positive test with vertigo and nystagmus provoked by the maneuver, and a latency period of 5-20 seconds 1, 5

Routine neuroimaging is not indicated when clinical criteria for BPPV are met, as it does not improve diagnostic accuracy and adds unnecessary cost 6, 1
Vestibular function testing is not needed when BPPV diagnosis is clear by clinical criteria, but may be indicated when diagnosis is unclear or patient remains symptomatic after treatment 6, 5
Brain MRI with and without contrast may be indicated when central vertigo is suspected based on red flags 5

BPPV is the most common cause of vertigo, accounting for 42% of general practice vertigo cases, characterized by brief positional episodes 2, 4
Vestibular neuritis is an acute severe vertigo lasting days without hearing loss, accounting for 41% of cases 3, 4
Ménière's disease is characterized by episodic vertigo with fluctuating hearing loss, tinnitus, and aural fullness, accounting for 10% of cases 3, 4
Vestibular migraine is a central cause of vertigo, accounting for 3.2% of cases, characterized by attacks lasting hours with migraine history 3, 5
Stroke or TIA may present with isolated vertigo in 10% of cerebellar strokes, and should be suspected in patients with neurological signs or symptoms 3, 5, 4

Missing cerebellar stroke, which can present similarly to peripheral vestibular disorders, and always assessing for neurological signs is crucial 5, 4
Overlooking medication effects, such as aminoglycosides and other ototoxic drugs that can cause vestibular toxicity, is important 4
Misinterpreting nystagmus, as pure vertical nystagmus without torsion is central until proven otherwise, is critical 5, 4
Ignoring treatment failure, as lack of response to repositioning maneuvers after 2-3 attempts mandates evaluation for central pathology, is essential 5