Sensation of the room (or themselves) spinning or moving
Must distinguish from lightheadedness, presyncope, orthostasis, and disequilibrium (unsteady on feet) via history
Distinguishing between central vs peripheral pattern is useful for workup and management
Central pattern: continuous symptoms independent of position and may have other FND
Peripheral pattern: positional, no other FND
Causes best differentiated based on chronicity and triggers rather than description of symptoms
Etiologies
BPPV: loose otoliths; short duration (<1min), very positional, nystagmus is horizontal and torsional, towards affected ear with posterior canal being most commonly involved; treat with otolith repositioning maneuvers
Vestibular neuritis/labyrinthitis: typically follows URI or ear infection with unidirectional nystagmus away from affected ear; self-limited, but if severe/prolonged can treat with steroids
Meniere’s disease: Vertigo, tinnitus, and low range frequency hearing loss. Gradually progressive. Treated with diuretics, salt restriction, Meclizine, and sometimes surgery or intratympanic injections
Endolymphatic leak: Usually following trauma or concussive blasts. Requires ENT evaluation and management. Classically a loud sound will cause vertigo and nystagmus
Vestibular migraine: episodic vertigo associated with headaches; usual migraine triggers, may have aura; often positive family history of migraine
Stroke: Typically due to posterior circulation infarct; sudden onset; rare cause of isolated vertigo; ask about vascular risk factors. Also consider vertebral dissection or vertebrobasilar insufficiency
Drug-induced: assess recent changes in medications; includes codeine, aminoglycosides, macrolides, sulfamethoxazole, NSAIDs, prednisone, anti-malarials, diuretics, beta-blockers, alpha-antagonists, lithium, antipsychotics
Other causes: demyelinating disease (MS), epileptic vertigo (focal seizures), Ramsay-Hunt syndrome (Herpes zoster oticus), cerebellopontine angle tumors (often little vertigo as CNS compensates as tumor slowly grows)
Evaluation and Management
HINTS Battery – Head Impulse test, Nystagmus pattern, Test of Skew
Only useful if pt is currently symptomatic
Central pattern: no corrective saccade, multidirectional nystagmus, skew present
Peripheral pattern: corrective saccade, unidirectional nystagmus, no skew present
Central patterns will need head and vessel imaging looking for vertebral dissection or basilar clots
Often, central vertigo is due to centrally acting medications
Peripheral causes are varied and often require evaluation by ENT as an outpt
Treatment with anticholinergics like meclizine or scopolamine is often helpful; antiemetics if significant nausea; and benzodiazepines for refractory acute attacks
