Some Causes of Dizziness and Vertigo
Cause | Suggestive Findings | Diagnostic Approach |
|---|---|---|
Peripheral vestibular system disordersa,b | ||
Severe, brief (< 1 minute) spinning triggered by moving head in a specific direction Nystagmus that has a latency of 0 to 30 seconds, is fatigable, and is torsional, beating toward the undermost ear Frenzel lenses needed to prevent visual fixation Hearing and neurologic examination intact | Dix-Hallpike maneuver to assess characteristic positional nystagmus | |
Recurrent episodes of unilateral tinnitus, hearing loss, ear fullness | Audiometry Gadolinium-enhanced MRI to rule out other causes | |
Vestibular neuronitis (viral cause suspected) | Sudden, incapacitating, severe vertigo with no hearing loss or other findings Lasts up to 1 week, with gradual lessening of symptoms Positional vertigo may result | Sometimes clinical examination alone Sometimes gadolinium-enhanced MRI Positional vertigo in neuronitis can be differentiated from BPPV by a Dix-Hallpike maneuver |
Labyrinthitis (viral or bacterial) | Hearing loss, tinnitus | Audiometry Temporal bone CT if purulent infection suspected Gadolinium-enhanced MRI if unilateral hearing loss and tinnitus |
Otitis media (acute or chronic, sometimes with cholesteatoma) | Ear pain, abnormal ear examination, including discharge if chronic otitis History of infection | Audiometry With cholesteatoma, CT optional to rule out semicircular canal fistula formation |
Trauma (eg, tympanic membrane rupture, labyrinthine contusion, perilymphatic fistula, temporal bone fracture, postconcussion) | Trauma obvious on history Other findings depending on location and extent of damage | Sometimes clinical examination alone Sometimes CT |
Vestibular schwannoma (acoustic neuroma) | Slowly progressive unilateral hearing loss, tinnitus, dizziness, dysequilibrium Rarely, facial numbness, weakness, or both | Audiometry Gadolinium-enhanced MRI if significant hearing asymmetry or unilateral tinnitus |
Treatment with aminoglycoside drugs recently instituted, usually with bilateral hearing loss and vestibular loss | Audiometry Sometimes vestibular evaluation with electronystagmography and rotary chair tests | |
Herpes zoster oticus (Ramsay Hunt syndrome) | Also affects geniculate ganglion, so facial weakness and taste loss often manifest along with hearing loss Vertigo possible but not typical Vesicles present on pinna and in ear canal | Clinical examination alone |
Chronic motion sickness (mal de debarquement) | Persistent symptoms after acute motion sickness | Clinical examination alone |
Central vestibular system disordersd | ||
Brain stem hemorrhage or infarction | Sudden onset Involvement of cochlear artery possibly causing ear symptoms | Immediate imaging (Gadolinium-enhanced MRI if available, otherwise CT) |
Cerebellar hemorrhage or infarction | Sudden onset, with ataxia and other cerebellar findings, often headache Deteriorates rapidly | Immediate imaging (Gadolinium-enhanced MRI if available, otherwise CT) |
Episodic, recurrent vertigo, usually without unilateral auditory symptoms (may have tinnitus that is usually bilateral) Possibly headache, but often personal or family history of migraine Photophobia, phonophobia, visual or other auras possible, helping make diagnosis | Usually clinical examination but with brain imaging as needed to rule out other causes Sometimes trial of migraine prophylaxis | |
Varied CNS motor and sensory deficits, with remissions and recurring exacerbations | Gadolinium-enhanced MRI of brain and spine | |
Vertebral artery dissection | Often head and neck pain | Magnetic resonance angiography |
Vertebrobasilar insufficiency | Intermittent brief episodes, sometimes with drop attacks, visual disturbance, confusion | Magnetic resonance angiography |
Global disturbance of CNS functione | ||
Pallor, weakness, sometimes heme-positive stool | Complete blood count | |
CNS-active drugsf (not ototoxic) | Drug recently instituted or dose increased; multiple drugs, particularly in an older patient Symptoms unrelated to movement or position | Sometimes clinical examination alone Sometimes drug levels (certain anticonvulsants) Sometimes trial of withdrawal |
Hypoglycemia (usually caused by drugs for diabetes) | Recent dose increase Sometimes sweating | Fingerstick glucose test (during symptoms if possible) |
Hypotension (caused by cardiac disorders, antihypertensives, blood loss, dehydration, or orthostatic hypotension syndromes including postural orthostatic tachycardia syndrome and other dysautonomias) | Symptoms on arising, sometimes with vagal stimulation (eg, urination) but not with head motion or while recumbent Manifestation possibly dominated by cause (eg, blood loss, diarrhea) | Orthostatic vital signs, sometimes with tilt table test, ECG |
Tachypnea Often history of lung disease | Pulse oximetry | |
Other causese | ||
Persistent perceptual postural dizziness (PPPD) | Chronic non-spinning dizziness (an internal sensation of swaying) persisting for > 3 months Can be precipitated by other acute conditions such as BPPV or vestibular migraine Can be a manifestation of anxiety disorder | Clinical examination alone |
Pregnancy | May be unrecognized | Pregnancy test |
Psychiatric (eg, panic attack, hyperventilation syndrome, anxiety, depression) | Symptoms chronic, brief, recurrent Unrelated to movement or position but may occur with stress or upset Neurologic and otologic examinations normal Initially, patient may be diagnosed with peripheral vestibular dysfunction and fail to respond to appropriate management | Clinical examination alone |
Chronic symptoms with bilateral hearing loss, fluctuating, with episodic vertigo | Audiometry Syphilis serology | |
Weight change Heat or cold intolerance | Thyroid function testing | |
Uncompensated peripheral vestibular weakness | Dysequilibrium Visual blurring (an internal sensation of swaying) with head turning Can follow episodes of vestibular neuronitis, migraine with vertigo, Meniere disease or after head trauma or inner ear surgery | Vestibular testing |
a Symptoms are typically paroxysmal, severe, and episodic rather than continuous. Ear symptoms (eg, tinnitus, fullness, hearing loss) usually indicate a peripheral disorder. Loss of consciousness is not associated with dizziness due to peripheral vestibular pathology. b Peripheral vestibular system disorders are listed in rough order of frequency of occurrence. c d Ear symptoms are rarely present, but gait/balance disturbance is common. Nystagmus is not inhibited by visual fixation. e These causes should not cause otic symptoms (eg, hearing loss, tinnitus) or focal neurologic deficits (sometimes occurs with hypoglycemia). Vertiginous symptoms are rare but have been reported. f There are numerous drugs, including most antianxiety, anticonvulsant, antidepressant, antipsychotic, and sedative drugs. Drugs used to treat vertigo are also included. BPPV = benign paroxysmal positional vertigo; CNS = central nervous system; URI = upper respiratory infection. | ||