This page compiles our content related to vertigo. For further information on diagnosis and treatment, follow the links below to our full BMJ Best Practice topics on the relevant conditions and symptoms.
Introduction
Relevant conditions
Assessment of dizziness | go to our full topic on Assessment of dizziness Patients may use the term dizziness to describe vertigo, pre-syncope, disequilibrium and lightheadedness (or non-specific dizziness). Dizziness is a common symptom: the prevalence in the general population ranges from 15% to 30%, and approaches 50% for patients aged over 85 years.[3][4][5] The most common aetiologies in a primary care setting are vestibular, cardiovascular, neurological, and psychogenic.[6] These all present with vertigo symptoms. |
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Benign paroxysmal positional vertigo | go to our full topic on Benign paroxysmal positional vertigo A peripheral vestibular disorder characterised by sudden-onset, severe attacks of vertigo usually lasting <30 seconds and precipitated by specific head movements (e.g., looking up or bending down, getting up, turning the head, or rolling over to one side in bed).[7] Primary (idiopathic) benign paroxysmal positional vertigo (BPPV) has a peak incidence between 50 and 70 years of age, but can occur in any age group.[8] Diagnosis is clinical with other key diagnostic factors including episodic vertigo (repeated attacks over days, weeks, or months), absence of associated neurological or otological symptoms, normal neurological examination, and positive Dix-Hallpike manoeuvre (posterior canal BPPV) or positive supine lateral head turn (lateral canal BPPV). |
Meniere's disease | go to our full topic on Meniere's disease Auditory and vestibular disease characterised by an episodic, sudden onset of vertigo; hearing loss and roaring tinnitus; and a sensation of pressure or discomfort in the affected ear. Vertigo lasts minutes to hours and may be associated with nausea and vomiting. Hearing loss is usually worse during acute attacks, especially in early stages of the disease. As the disease progresses, hearing loss increases in severity and may become constant. Meniere’s disease (MD) is primarily a disease of adulthood, although several cases have been reported in children. Onset usually occurs in the fourth decade.[9] Risk factors for MD include positive family history, recent viral infection, and autoimmune disorders. |
Labyrinthitis | go to our full topic on Labyrinthitis An inflammatory condition, which affects the labyrinth in the cochlea and vestibular system of the inner ear. Viral labyrinthitis is typically associated with a preceding upper respiratory tract infection. Other aetiological viral agents include varicella zoster virus, cytomegalovirus, mumps, measles, rubella, and HIV.[10][11] Bacterial labyrinthitis is associated with acute or chronic otitis media, meningitis, and cholesteatoma. Labyrinthitis may also manifest in certain autoimmune inner ear conditions (e.g., Cogan's syndrome or Behcet's disease).[12] Patients typically present with severe room-spinning vertigo and associated nausea and vomiting. They may have unilateral hearing loss and tinnitus. Most acute episodes are short-lived and self-limited. |
Vestibular migraine | A common cause of vertigo and the most common cause of spontaneous episodic vertigo.[1][13] It affects approximately 20% of patients with migraine.[14] Symptoms include spontaneous and positional vertigo, head motion vertigo/dizziness and ataxia, all of variable duration, ranging from seconds to days, and independent of migraine associated headache.[1][13] Photophobia, phonophobia, or aura may be diagnostic symptoms.[1] |
Vestibular neuritis | go to our full topic on Vestibular neuritis Balance disorders may be caused by disorders at the level of the vestibular apparatus, cerebellum or brainstem, extrapyramidal, spinal cord, or neuromuscular system. A thorough history will indicate the most likely system to be causing the balance disorder. Balance disorders should be distinguished from syncope or pre-syncope, in which degrees of loss of consciousness occur and which are likely to be due to cardiovascular or neurovascular causes, and require urgent evaluation. The prevalence of balance problems at aged 70 years is reported to be 36% in women and 29% in men.[15] |
Post-traumatic vertigo | Typically, occurs as a result of blunt head trauma such as a fall, an assault, or a motor vehicle accident. Presenting symptoms may be of a traumatic perilymphatic fistula or post-traumatic Meniere's disease.[16] Patients may complain of vertigo, disequilibrium, tinnitus, pressure, headache, and diplopia. Other causes are post-surgical (middle-ear surgery, cochlear implantation) and diving.[17][18][19] Superior semicircular canal dehiscence should be differentiated from post-traumatic vertigo; it is characterised by episodes of vertigo associated with loud sounds and/or altered middle-ear pressure.[20] |
Cerebrovascular causes | Dizziness is a common presenting feature in cerebrovascular events. Cerebellar stroke (due to infarction or haemorrhage) may present in a similar fashion to peripheral causes of vertigo with sudden intense vertigo, nausea, and vomiting. Nystagmus (bilateral or vertical) may suggest a central cause of the vertigo. Other neurological signs include limb ataxia and impaired gait. Patients with cerebellar stroke usually cannot stand without support, even with the eyes open, whereas a patient with acute vestibular neuritis or labyrinthitis is usually able to do so. Unlike peripheral causes, the head-impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting).[21] Urgent magnetic resonance imaging should be requested in all patients with acute vertigo who have significant risk factors for a cerebellar stroke, such as hypertension, diabetes mellitus, smoking, and cardiovascular disease, since it is possible that central signs on examination may not present. |
Neoplastic causes | Intracranial tumours and vestibular schwannomas may present with vertigo, as well as other symptoms such as signs of intracranial pressure (e.g., headache, altered mental status, nausea, and/or vomiting) and gait abnormality. Cranial nerve deficits may also manifest.[21] Neuroimaging with computed tomography/magnetic resonance imaging is essential. |
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