Differential Diagnosis of Dizziness

Primary Diagnostic Categories by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery recommends categorizing dizziness into four distinct vestibular syndromes: Acute Vestibular Syndrome, Triggered Episodic Vestibular Syndrome, Spontaneous Episodic Vestibular Syndrome, and Chronic Vestibular Syndrome, based on timing and triggers 1, 2
Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of peripheral vertigo, characterized by vertigo lasting less than 1 minute, triggered by specific head position changes, with a strength of evidence level of high 1, 3
Vestibular neuritis is a viral infection causing severe rotational vertigo lasting 12-36 hours with decreasing disequilibrium over 4-5 days, without hearing loss, tinnitus, or aural fullness, with a strength of evidence level of moderate 1, 3
Posterior circulation stroke is a critical diagnosis requiring urgent identification, with 75-80% of patients having no focal neurologic deficits on standard examination, with a strength of evidence level of high 4

The presence of hearing loss, tinnitus, or aural fullness strongly suggests Ménière's disease, labyrinthitis, or vestibular schwannoma, with a strength of evidence level of moderate 3, 2
Unilateral or pulsatile tinnitus warrants MRI with contrast to exclude vestibular schwannoma or vascular malformation, with a strength of evidence level of high 2, 4

The American Academy of Otolaryngology-Head and Neck Surgery advises against relying on patient descriptions of "spinning" versus "lightheadedness" and instead focusing on timing, triggers, and duration, with a strength of evidence level of low 1, 2, 5
The American Heart Association recommends against assuming a normal neurologic examination excludes stroke, as 75-80% of patients with posterior circulation infarct have no focal neurologic deficits on standard examination, with a strength of evidence level of high 4

The Dix-Hallpike maneuver is the gold standard for BPPV diagnosis, with a positive test showing 5-20 second latency, torsional upbeating nystagmus toward the affected ear, and symptoms resolving within 60 seconds, with a strength of evidence level of high 2, 4
The HINTS examination has 100% sensitivity for detecting stroke in acute vestibular syndrome when performed by trained practitioners, with a strength of evidence level of high 2, 4