Approach to Vertigo & Dizziness

Vertigo accounts for ~54% of presentations for “dizziness. Other causes: disequilibrium (imbalance), lightheadedness (giddiness), and pre-syncope. “Drugs are a common contributor at any of these — antihypertensives, anticonvulsants, antidepressants and sedatives can all cause dizziness, via postural hypotension or a direct central/peripheral vestibular effect.

Vertigo may be central or peripheral.

• Central — posterior circulation stroke/TIA, multiple sclerosis, tumours. Usually has associated neurological signs: weakness, dysarthria, sensory change, ataxia, confusion. Vascular risk factors raise the pre-test probability.
• Peripheral — more likely associated with nausea, vomiting and hearing loss.

History

• Recent URTI → vestibular neuronitis/labyrinthitis.
• Hearing loss or tinnitus → labyrinthitis or Meniere’s disease.
• Central red flags: cardiovascular risk factors, gait ataxia out of proportion to vertigo, visual field loss, diplopia, hemi-sensory loss, slurred speech, limb weakness, dysphagia, skew deviation or direction-changing nystagmus.

Examination

• Otoscopy — herpes zoster vesicles, cholesteatoma retraction pockets, otitis media.
• Neuro exam — gait ataxia, Romberg balance, coordination, cerebellar signs (pronator drift, finger-nose, heel-shin).
• Eyes — nystagmus: vertical suggests a central cause; disappearing with gaze fixation suggests peripheral; rotational suggests BPPV.
• Cardiovascular — postural BP, heart rhythm, carotid bruits.
• Dix-Hallpike — diagnoses BPPV (horizontal nystagmus ± vertigo triggered by the manoeuvre).
• Head impulse test — patient fixates on the examiner’s nose while the head is rapidly rotated 10–20°; a corrective eye-movement back to the nose is abnormal and indicates a peripheral lesion. Positive in vestibular neuronitis but negative with a cerebellar infarct — a useful bedside discriminator when the two can otherwise look alike.

Differential diagnosis

Cause	Onset/duration	Trigger	Key features
BPPV	Seconds	Head position change	Positional, positive Dix-Hallpike, no hearing loss
Vestibular neuronitis	Seconds–minutes, then gradual recovery over 2–6 weeks	Often follows a URTI	Imbalance prominent; nystagmus fast-phase away from the lesion; hearing preserved
Labyrinthitis	Seconds–minutes	Head position change	Tinnitus + hearing loss present (distinguishes it from vestibular neuronitis)
Meniere’s disease	Hours	Spontaneous	Fluctuating sensorineural hearing loss, tinnitus, aural fullness

Investigations

Blood glucose should be checked in all patients presenting with vertigo; other bloods are not routine. Imaging (CT/MRI/MRA, with neurology referral) is indicated if the examination doesn’t fit a peripheral lesion, vascular risk factors are prominent, neurological signs/symptoms are present, or vertigo is accompanied by headache.

Management

BPPV — an otolith particle-repositioning manoeuvre (Epley or Semont). A Cochrane review of 11 trials (745 participants) found the Epley manoeuvre significantly more effective than a sham manoeuvre or control for complete resolution of vertigo (odds ratio 4.42), with the proportion resolving rising from 21% to 56%; it performed similarly to the Semont and Gans manoeuvres and better than Brandt-Daroff exercises. Recurrence is common (36% in the review) and adverse effects are mild (transient nausea in up to a third).

Vestibular neuronitis/labyrinthitis — bed rest and short-course (24–72 hour) vestibular sedatives/antiemetics for the acute phase, then vestibular adaptation exercises or formal rehabilitation in the recovery phase; most resolve over weeks. Suppurative labyrinthitis (from spreading otitis media) needs urgent ENT referral for drainage.

Meniere’s disease — a low-salt diet ± diuretic is first-line maintenance treatment; betahistine is the usual mainstay for symptomatic control, though relapse is common and refractory cases may need intra-tympanic gentamicin or surgery.

Vestibular sedatives (antihistamines, benzodiazepines, prochlorperazine) are for short-term symptomatic relief of acute vertigo only — evidence for them is largely anecdotal, and prolonged use can impair vestibular adaptation. Benzodiazepines should be avoided given their addictive potential; avoid long-term dependence on any of these agents.

Refer to a specialist for continuous (rather than episodic) vertigo, progressive hearing loss, severe or unusual headache, cerebellar signs, or where the diagnosis remains unclear.