Vertigo can result from dysfunction of the labyrinthine apparatus (peripheral vertigo) or their connections to the brainstem (central vertigo). Thus numerous etiologies can cause vertigo, with the differential diagnosis varying by age and comorbid risk factors. A detailed history of persistent versus episodic symptoms, provoking factors, recent medications, and associated signs and symptoms is essential.
Causes of peripheral vertigo include benign paroxysmal positional vertigo (BPPV), vestibular neuronitis, trauma (labyrinthine concussion), fistula, autoimmune disorders, and Meniere disease.
- BPPV, the most common cause, lasts seconds to a minute or so and is provoked by positional changes of the head. It can occur after head trauma or inner ear infection but is most commonly spontaneous in the elderly.
- Vestibular neuronitis is accompanied by significant nausea with no other neuro-otologic signs, occasionally following a viral illness.
- Labyrinthine concussion occurs post-trauma, sometimes accompanied by hearing loss; when there is a transverse fracture, the facial nerve may be involved.
- Meniere disease typically presents with episodic vertigo, tinnitus, and hearing loss due to disordered fluid homeostasis in the inner ear. It is bilateral in about a quarter of cases and can lead to permanent hearing loss, especially if untreated.
- Vertigo associated with migraine can last up to 72 hours. Vestibular migraine should be considered in patients who have comorbid history of episodic headache. Anxiety and migraine are comorbidities, so distinguishing these two entities may difficult and they may coexist.
- Stroke is seen in patients with vascular risk factors such as hypertension, diabetes, and hyperlipidemia, and risk also increases with age. Vertebral artery dissection can be traumatic or spontaneous and often has accompanying neck pain. Stroke will most often present with cranial nerve or cerebellar signs.
- Multiple sclerosis is seen in a younger cohort, and isolated vertigo can be encountered. Many patients will have a history of other transient (days, not seconds) neurologic symptoms when queried.