Vertigo: Comprehensive Overview and Management
Vertigo is the sensation of spinning or swaying, caused by asymmetric input to the vestibular system. It must be differentiated from general dizziness, presyncope, and imbalance. Diagnosis relies on distinguishing between peripheral causes (inner ear) and potentially dangerous central causes (CNS lesions) through targeted clinical evaluation and maneuvers like the HINTS exam.
Key Takeaways
Vertigo is a specific spinning sensation, distinct from general dizziness or lightheadedness.
Central vertigo often signals serious CNS issues like stroke or tumors, requiring urgent imaging.
Peripheral vertigo stems from inner ear problems, commonly BPPV, Meniere disease, or neuritis.
The HINTS exam is crucial for rapidly differentiating acute central from peripheral causes.
What is vertigo and how does it differ from dizziness or presyncope?
Vertigo is specifically defined as the sensation of spinning or swaying, whether the environment feels like it is moving (external) or the person feels they are moving (internal). This sensation arises from an imbalance, or asymmetric input, within the vestibular system. It is crucial to differentiate true vertigo from the broader term 'dizziness,' which acts as an umbrella term encompassing nonvertiginous disturbances in spatial orientation, including imbalance, confusion, and presyncope. Presyncope, characterized by severe lightheadedness or near loss of consciousness, is typically caused by systemic issues like low blood pressure or hypoxia, not vestibular asymmetry.
- Vertigo: Sensation of spinning or swaying, caused by asymmetric vestibular input.
- Dizziness (Umbrella Term): Nonvertiginous disturbance in spatial orientation, including vertigo, presyncope, imbalance, and confusion.
- Presyncope (Distinction): Severe lightheadedness or near loss of consciousness, usually due to low systemic blood pressure or hypoxia.
What are the primary causes of vertigo, categorized as central or peripheral?
Vertigo is fundamentally categorized based on the location of the underlying pathology: central vertigo originates from lesions within the Central Nervous System (CNS), while peripheral vertigo arises from issues in the inner ear or the vestibulocochlear nerve. Central causes are often more serious, involving conditions like stroke, TIA, or posterior fossa tumors, and require immediate neurological attention. Peripheral causes are far more common and generally benign, including conditions such as Benign Paroxysmal Positional Vertigo (BPPV), Meniere Disease, or vestibular neuritis, which affect the balance organs directly.
- Central Vertigo (CNS Lesions): Includes ischemia/hemorrhage (Stroke, TIA), posterior fossa tumors (Schwannoma), migraine (Vestibular Migraine), and demyelination (e.g., MS).
- Peripheral Vertigo (Inner Ear/Vestibulocochlear Nerve): Includes Vestibular Neuritis/Labyrinthitis, BPPV (Canal Debris), Meniere Disease (Endolymphatic Hydrops), and toxicity (Aminoglycoside).
How do the clinical features of central and peripheral vertigo compare?
Differentiating central from peripheral vertigo is critical for determining urgency and treatment, relying heavily on associated clinical features. Peripheral vertigo typically presents with severe spinning but often lacks significant neurological signs, though hearing loss and tinnitus are common. Conversely, central vertigo may be less intense but is frequently accompanied by 'Dangerous D's' such as dysmetria, dysphagia, or diplopia, indicating brainstem or cerebellar involvement. Furthermore, the nature of the nystagmus differs; peripheral nystagmus is usually unidirectional and horizontal, whereas central nystagmus can be vertical, torsional, or change direction, signaling a more concerning origin.
- Central vs. Peripheral Comparison: Central vertigo often involves marked neurological signs (Dysmetria, Diplopia), while peripheral signs are typically absent.
- Nystagmus Differences: Peripheral nystagmus is unidirectional and horizontal; central nystagmus can be horizontal, torsional, or vertical (down-beat).
- Associated Symptoms: Hearing loss and tinnitus are common with peripheral causes but rare in central vertigo.
- Vestibular Syndromes (Chronicity): Vertigo can manifest as acute (continuous, days to weeks), episodic (recurrent, seconds to hours), or chronic (continuous, weeks to years).
What diagnostic steps are used to evaluate and diagnose the cause of vertigo?
The clinical evaluation of vertigo begins with a focused history and physical exam, often guided by the TiTrATE framework (Timing, Triggers, Associated Features) to classify the syndrome. Key diagnostic steps involve targeted maneuvers to provoke symptoms and assess vestibular function. For acute vestibular syndrome, the HINTS exam (Head Impulse, Nystagmus, Test of Skew) is essential, as specific findings (like a normal head impulse test) strongly suggest a central cause, often summarized by the INFARCT mnemonic. For episodic or triggered vertigo, the Dix-Hallpike maneuver is used to diagnose BPPV. If central pathology is suspected based on the exam, urgent neuroimaging, such as MRI/MRA, is mandatory.
- Focused History & Exam: Utilize TiTrATE (Timing, Triggers, Associated Features) and check neurological exam (Cerebellar features, CNs) and orthostatic vitals.
- HINTS Exam Components: Head Impulse, Nystagmus, Test of Skew, used for acute vestibular syndrome differentiation.
- Central Suggestion (INFARCT): Impulse Normal, Fast-phase Alternating, Refixation, indicating a high likelihood of CNS involvement.
- Diagnostic Approach: Suspected central causes require urgent neuroimaging; high likelihood peripheral causes allow for empiric management and ENT referral.
How is vertigo managed, depending on whether the cause is central or peripheral?
Management strategies for vertigo are dictated by the underlying etiology, prioritizing the exclusion of life-threatening central causes. If the HINTS exam or neurological deficits suggest central vertigo, immediate admission and urgent workup for conditions like stroke are necessary, focusing treatment on the underlying pathology. For peripheral vertigo, management involves treating the specific condition, such as performing the Epley maneuver for BPPV. Symptomatic relief can be provided using vestibular suppressants like antihistamines or benzodiazepines, but these should only be used short-term. Chronic use of suppressants is cautioned against because it inhibits the brain's natural ability to compensate for the vestibular deficit, prolonging recovery.
- Central Vertigo Management: Requires urgent workup for stroke if deficits are present, followed by treatment of the underlying condition.
- Peripheral Vertigo Treatment: Focuses on treating the specific cause (e.g., Epley maneuver for BPPV).
- Symptomatic Pharmacotherapy: Short-term use of vestibular suppressants (Antihistamines, Benzodiazepines) for relief.
- Caution on Suppressants: Chronic use inhibits central compensation, potentially delaying long-term recovery.
Frequently Asked Questions
What is the most common cause of peripheral vertigo?
The most common cause is Benign Paroxysmal Positional Vertigo (BPPV), which is caused by canal debris (otoconia) dislodged in the inner ear canals. It is diagnosed using the Dix-Hallpike maneuver and treated with repositioning maneuvers like the Epley.
Why is the HINTS exam important in acute vertigo?
The HINTS exam rapidly differentiates between benign peripheral causes and dangerous central causes, such as stroke, in patients with acute vestibular syndrome. A finding suggesting INFARCT (Impulse Normal, Fast-phase Alternating, Refixation) indicates central pathology.
Should vestibular suppressants be used long-term for vertigo?
No, vestibular suppressants like benzodiazepines should only be used short-term. Chronic use inhibits the brain's natural central compensation mechanism, which is necessary for long-term recovery and adaptation to vestibular deficits.
