Differential Diagnosis of Vertigo

Initial Classification by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery recommends classifying vertigo into four distinct vestibular syndromes based on timing and triggers to narrow diagnostic possibilities and guide evaluation 1, 2

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo, accounting for 42% of cases in general practice, characterized by brief episodes (<1 minute) triggered by specific head position changes 1, 2
Central Paroxysmal Positional Vertigo is a rare central mimic of BPPV that fails to respond to repositioning maneuvers 1
Perilymphatic Fistula is a cause of positional vertigo following trauma or barotrauma 1
Superior Canal Dehiscence Syndrome is characterized by vertigo triggered by loud sounds or Valsalva maneuvers 1
Ménière's Disease is an episodic vertigo lasting 20 minutes to hours with fluctuating hearing loss, tinnitus, and aural fullness, accounting for 10% of cases 1, 2
Vestibular Migraine is characterized by vertigo attacks lasting hours with migraine history, accounting for 3.2% of cases 1, 2, 3, 4
Vertebrobasilar Insufficiency/TIA is characterized by episodes typically <30 minutes without hearing loss, may precede stroke by weeks to months 3, 4, 5
Vestibular Neuritis is an acute severe continuous vertigo lasting days without hearing loss, accounting for 41% of cases 1, 2
Labyrinthitis is similar to vestibular neuritis but with associated hearing loss 1
Posterior Circulation Stroke is a cerebellar or brainstem infarction, with 10% of cerebellar strokes presenting with isolated vertigo, and 75-80% of posterior circulation strokes causing acute vestibular syndrome lacking focal neurologic deficits initially 6, 2

Peripheral vertigo is characterized by nystagmus with a horizontal and rotatory component, unidirectional, suppressed by visual fixation, and fatigable with repeated testing 2
Central vertigo is characterized by nystagmus that is pure vertical without torsional component, direction-changing without head position changes, and not suppressed by visual fixation 2
Severe postural instability, such as inability to stand or walk, suggests central pathology 3, 4, 5

The Dix-Hallpike maneuver is used to diagnose BPPV, with a positive test characterized by vertigo and nystagmus with 5-20 second latency period, fatigable with repetition 2
The HINTS examination, including head impulse test, nystagmus type, and test of skew, has a sensitivity of 92.9% and specificity of 83.4% for central causes when performed by trained clinicians 3, 4, 5

Persistent BPPV that fails to respond to 2-3 particle repositioning maneuvers warrants thorough neurological examination and consideration of MRI to exclude CNS pathology 7, 2
Atypical features, such as absence of typical positional triggers, presence of neurologic symptoms, or unusual nystagmus patterns, should prompt reevaluation 7, 3
CNS disorders masquerading as BPPV are found in 3% of treatment failures, with acute brain lesions detected in 6% on CT and 11% on MRI in patients with central paroxysmal positional vertigo 7, 6