Vertigo Algorithm and Differential Diagnosis

  • Post category:Neurology

Is it True Vertigo ?

  • The Approach (Questions)
    • Is the dizziness true vertigo
    • If so, is it central or peripheral vertigo
    • Is the vertigo intermittent → likely benign
    • Constant vertigo is either acute peripheral vestibulopathy (APV) or a posterior circulation/cerebellar CVA

  • General Dizziness: 4 different etiologies
    • Lightheadedness/Presyncope
    • Vertigo
    • Dysequilibrium (neuromuscular disorder)
    • Psychiatric
  • Definitions (Rosen’s Emerg Med, 6th ed. Ch 13. 2006)
    • True Vertigo: disorientation in space combined with a sense of motion
    • Hallucination of movement of self (subjective vertigo) or of environment (objective vertigo)

Central vs Peripheral Vertigo

General Approach

  • Objective for vertigo is differentiating benign peripheral vertigo from life-threatening central vertigo, using the 5 criteria


  • Cerebellar CVA: acute onset and continuous
    • Other central vertigo is usually more gradual and continuous
  • APV (acute peripheral vestibulopathy): gradual onset and continuous
  • BPPV: Acute onset but intermittent


  • Central vertigo:
    • Vertical
    • Unilateral
    • Non-fatigable
    • Unsupressed: not suppressed with fixation of gaze (nystagmus persistent when looking straight at your finger)
    • Direction change: direction of nystagmus changes with eccentric gaze
  • Vertical nystagmus ddx: central vertigo, PCP, EtOH (alcohol), drugs

Neurologic symptoms

  • Neuro exam: 6Ds of an abnormal neuro exam:
    • Dizziness (vertigo)
    • Diplopia (double vision)
    • Dysphagia (difficulty swallowing)
    • Dysarthria (difficulty speaking)
    • Dysmetria (cerebellar ataxia)
    • Dysdiadochokinesia (impaired ability to perform rapid, alternating movements)
  • Long-tract signs
    • Motor/sensory loss
  • Ataxia
    • Central vertigo/cerebellar pts usually unable to walk

Auditory symptoms

  • Auditory symptoms a sign of peripheral vertigo (acute labrynthitis)


□ Dizziness
□ Diplopia
□ Dysphagia
□ Dysarthria
□ Dysmetria
□ Dysdiadochokinesia

HiNTS Test (Stroke 2009;40:3504-10)

  • Head impulse test (Hi): (NEJM 2003;348:1027-32)
    • Bedside test of horizontal VOR (vestibuloocular reflex)
    • Start: Head turned to one side and eyes turned 10º from center to same side
    • Motion: Apply brief high acceleration head turn so that eyes end looking at examiner’s nose
    • Test: Catch up saccades on one side, but not the other indicates peripheral vestibular lesion on that side
  • Nystagmus (N)
    • Nystagmus changes direction on eccentric gaze → central lesion
  • Skew deviation (TS)
    • Eyes are vertically misaligned because of imbalance of vestibular tone → central lesion
    • Alternately cover each eye to test for realignment
  • Positive test (central lesion-stroke)
    • Normal horizontal head impulse test, direction-changing nystagmus in eccentric gaze, or skew deviation (vertical ocular misalignment)
    • HINTS Test 100% sensitive, 96% specific for identifying stroke (Stroke 2009;40:3504-10)

Risk factor Assessment

  • Isolated vertigo can be the only symptom in cerebellar stroke/TIA and posterior circulation hemorrhage
  • Risk factors: Older age, male sex, and the presence of hypertension, coronary artery disease, diabetes mellitus, and atrial fibrillation

Peripheral vertigo

1. Vestibulopathy (APV)


  • APV= Acute Peripheral Vestibulopathy or Acute Prolonged Vertigo
    • Prolonged vertigo definition: continuous vertigo lasting more than a few hours
    • Self limited, likely viral cause for symptoms → affecting peripheral vestibular portion of CN8 (Vestibulocochlear nerve)
  • Clinical
    • Symptoms: gradual onset and continuous vertigo
    • Neuro: Normal neuro exam and non-concerning type of nystagmus
    • Head thrust test: positive, catch up saccades on one side


  • Clinical Presentation
    • Develops over hours and resolves over days, usually post-viral
    • May mimic infarct type symptoms
  • Treatment
    • General (Antihistamines, anticholinergics, anti-emetics, benzodiazepines)
    • Directed treatment: Dexamethasone, valacyclovir


  • Subtypes
    • Toxic: usually medication induced, has auditory symptoms and tinnitus
    • Serous: associated ENT infection, May have fever
    • Suppurative: severe symptoms, febrile, toxic → Admit, IV Antibiotics, ENT C/S


  • Abrupt onset, h/o vascular dz, associated with neuro signs (also considered central type vertigo)


  • Associated with trauma, lifting, coughing, sneezing
  • Fistula test: Vertigo and nystagmus induced by pressure in the external ear canal



  • Free floating debris in posterior semicircular canal


  • Abrupt onset of vertigo seconds after change in head position, lasting less than a minute.
Differentiating Benign Paroxysmal Positional Vertigo From Vestibular Neuritis - Labyrinthitis
Differentiating Benign Paroxysmal Positional Vertigo From Vestibular Neuritis – Labyrinthitis


  • Dix-Hallpike
    • Use: for diagnosis, presence of paroxysmal positional nystagmus is most reliable finding in patients with BPPV (Am J Otol 1995;16:806-10)
    • Procedure:
      • Start: Seated with head turned 45º to side being tested
      • Motion: Quickly lower to supine position with head angled backward 45º off bed
      • Test positive: Nystagmus with affected side down, can continue to Epley from this position for treatment
      • Nystagmus is delayed in onset, fatiguable, and decreases with fixation
Classic Findings During Hallpike Test in Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV)
Classic Findings During Hallpike Test in Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV)


  • Canalith Repositioning Maneuvers
    • Epley and Semont (Ann Emerg Med 2001;37:392-8)
      • May not be better than standard medical therapy (J Emerg Med 2014;46(4):575)

3. Meniere’s disease

  • Clinical
    • Attacks of vertigo preceded/accompanied by reduced hearing, tinnitus and pressure in ear
    • Attacks followed by residual hearing loss
  • Treatment
    • Dietary restrictions (salt, caffeine, tobacco), Lasix, Betahistine, ENT referral
  • Other causes of Peripheral Vertigo
    • Ear canal foreign body, trauma (labyrinth concussion), otitis media, cerumen impaction, medication (aminoglycosides)
Medications for Acute Vertigo
Medications for Acute Vertigo

Central Vertigo

Cerebellar Stroke

Clinical Scenario

  • Symptoms
    • Sudden onset/continuous vertigo
    • +/- Severe headache
  • Nystagmus
    • Vertical, unilateral, nonfatigable, unsupressed
    • Skew deviation
  • Neurologic symptoms
    • 5Ds (Dizziness, Dysphagia, Dysphonia, Dysmetria, Diplopia)
    • Long tract signs (motor/sensory)
    • Ataxia (unable to ambulate)
  • Isolated vertigo
    • Definition: no other symptoms present except for vertigo
    • May simulate symptoms of vestibular neuritis (VN)
    • Cerebellar CVA vs VN (Neurology 2006;67:1178-83)
      • 10% isolated cerebellar infarct pts present with isolated vertigo symptoms (vestibular neuritis (VN) symptoms)
      • No patients with cerebellar infarct had a positive head thrust test


10% isolated cerebellar infarct patients present with isolated vertigo


  • CT
    • Can identify acute hemorrhage
    • Not sensitive for acute stroke (especially of posterior fossa)
    • Can identify large posterior CVA or mass effect (closed 4th ventricle)
  • MRI
    • Modality of choice to rule out infarctions
    • Indication: (NEJM 1998;339:680-5)
      • Neurologic signs/symptoms
      • Sudden onset of vertigo in a patient with risk factors for stroke
      • Headache: new, severe headache accompanying the vertigo

MRI for Vertigo

□ Neurologic symptoms
□ Sudden onset of vertigo + stroke risk factors
□ Headache: new and severe