Vertigo: A Structured Approach

Introduction

"Dizziness" is one of the most common and least specific presenting complaints in medicine, and the single most important step in assessment is working out what the patient actually means by it. Vertigo specifically refers to an illusion of movement, usually a spinning sensation, and implies a problem with the vestibular system or its central connections - this article sets out a framework for approaching it.¹

The three specific peripheral causes that account for the majority of vertigo presentations - BPPV, Meniere's disease, and vestibular neuritis/labyrinthitis - are each covered in their own article. This article focuses on the broader approach: separating vertigo from its mimics, recognising vestibular migraine and dangerous central causes, and structuring the work-up.

Is it actually vertigo?

Patients use "dizzy" to describe several different sensations, and asking them to describe the feeling without using the word "dizzy" is one of the most useful questions in the assessment.¹

Only the first category is true vertigo, and the rest of this article - and the vestibular causes covered elsewhere on this site - applies specifically to that group. Presyncope points towards a cardiovascular work-up; disequilibrium towards a neurological and falls assessment; non-specific lightheadedness often towards anxiety or medication review.

Classifying vertigo: peripheral versus central

Once true vertigo is confirmed, the next step is to localise it. Peripheral vertigo arises from the labyrinth or vestibular nerve and is generally more intense but has a better safety profile. Central vertigo arises from the brainstem or cerebellum and, while sometimes milder in intensity, can indicate a life-threatening cause.^1,2

Duration and triggers narrow the differential quickly: seconds and positional suggests BPPV; minutes-to-hours and episodic with aural symptoms suggests Meniere's; continuous over days suggests vestibular neuritis/labyrinthitis or, in the presence of vascular risk factors or central examination findings, stroke.

Vestibular migraine

Vestibular migraine is a common but frequently under-recognised cause of episodic vertigo, thought to affect up to 1% of the population, and is a leading differential wherever Meniere's disease is considered. Episodes last from minutes to 72 hours and can occur with or without headache at the same time as the vertigo, which often causes diagnostic confusion.³

Diagnosis rests on the association with migrainous features rather than on hearing loss: at least half of episodes are accompanied by headache, photophobia, phonophobia, or visual aura, and there is usually a personal or family history of migraine. Unlike Meniere's disease, hearing loss is not a feature, though mild transient aural fullness can occur.³

Management follows standard migraine principles: identifying and avoiding triggers, acute treatment of attacks, and migraine prophylaxis (e.g. a beta-blocker, tricyclic antidepressant, or topiramate) for frequent or disabling episodes.

History and examination

A structured history covers: the exact sensation (to confirm true vertigo), duration and frequency of episodes, triggers (position change, or spontaneous), associated otological symptoms (hearing loss, tinnitus, aural fullness), associated neurological or migrainous symptoms, cardiovascular risk factors, and a full medication history (looking for ototoxic or centrally acting drugs).¹

Examination should include: otoscopy and tuning fork tests; a Dix-Hallpike manoeuvre if positional vertigo is suspected; a HINTS exam for anyone with acute, continuous vertigo where a central cause needs to be excluded (both described in detail in their respective articles); gait and Romberg's test; a full cranial nerve and cerebellar examination; and lying and standing blood pressure to assess for orthostatic hypotension when presyncope is a possibility.

Investigations

Investigations should be targeted by the clinical picture rather than requested as a blanket panel:^1,2

• Pure tone audiometry: for any vertigo with hearing symptoms, or where Meniere's disease or a vestibular schwannoma is suspected
• MRI brain (with internal auditory meatus views): for suspected central causes, atypical or asymmetric presentations, or an abnormal HINTS exam
• Lying and standing blood pressure, ECG, and cardiovascular assessment: where presyncope is being considered
• Blood glucose and FBC: to exclude hypoglycaemia or anaemia contributing to non-specific dizziness
• Medication review: particularly for antihypertensives, sedatives, and known ototoxic drugs

Management principles

Management is directed at the underlying cause, detailed in the specific articles for BPPV (the Epley manoeuvre), Meniere's disease (lifestyle measures, betahistine, and escalation to intratympanic or surgical therapy), and vestibular neuritis/labyrinthitis (supportive care and vestibular rehabilitation). Vestibular migraine is managed with standard migraine strategies.

Across peripheral causes, short courses of a vestibular sedative (prochlorperazine or cyclizine) help control acute symptoms, but should not be continued long term, as prolonged use can delay the central compensation that ultimately resolves vertigo from a fixed peripheral deficit. Vestibular rehabilitation - a structured programme of exercises promoting habituation and compensation - benefits most patients with a persistent peripheral vestibular deficit, regardless of the specific cause.

Complications

• Falls and injury, particularly in older adults
• Reduced confidence and avoidance of activity, sometimes progressing to persistent postural-perceptual dizziness (a chronic functional dizziness disorder that can follow an initial organic trigger)
• Anxiety related to unpredictable episodes
• Missed diagnosis of a dangerous central cause if red flags are not recognised

Red flags

Prognosis

Prognosis depends entirely on the underlying cause: BPPV usually resolves quickly with repositioning, vestibular neuritis resolves over weeks with compensation, and Meniere's disease follows a fluctuating course over years. Vestibular migraine typically responds well to standard migraine management. The overarching principle is that identifying the correct cause, rather than treating "vertigo" as a single generic symptom, is what determines both the treatment and the prognosis.¹