Vertigo
The false sensation of self or environmental movement, classified as peripheral (inner ear or vestibular nerve) or central (brainstem or cerebellum) based on history, nystagmus pattern, and the bedside HINTS exam. Peripheral vertigo is managed with repositioning maneuvers or vestibular suppressants; central vertigo requires urgent stroke evaluation, since it can be the sole presenting symptom of a posterior circulation stroke.
- Topic reviewThe full article, organized the way the exam asks it.
- ABIM-format MCQsVignettes with an explanation for every wrong answer.
- Key factsThe numbers and thresholds worth memorizing, up front.
- AI tutorMedBrain answers the question you're stuck on.
What this article covers
- Overview
Vertigo is the false perception of movement, of oneself or the surrounding environment, typically described as spinning or whirling, distinct from presyncope, disequilibrium, or nonspecific lightheadedness.
- Epidemiology
One of the most common presenting complaints in outpatient and emergency settings, cutting across primary care, otolaryngology, and neurology.
- Risk factors
Vascular risk factors for central (stroke-related) vertigo: age, hypertension, diabetes, hyperlipidemia, smoking, atrial fibrillation, and prior stroke or transient ischemic attack.
- Pathophysiology
Peripheral vertigo arises from the labyrinth or vestibular nerve: a mismatch or abnormal signal from the semicircular canals, otolith organs, or vestibular nerve creates a false sense of motion; in…
- Clinical features
Onset, duration, and triggers narrow the differential more than the sensation itself: brief, recurrent, position-triggered episodes point to BPPV; a single sustained episode with a viral prodrome…
- Differential diagnosis
Benign paroxysmal positional vertigo: recurrent, seconds-long, position-triggered episodes with positional nystagmus and no auditory or neurologic findings; confirmed with the Dix-Hallpike maneuver.
- Diagnosis
The Head Impulse, Nystagmus, Test of Skew (HINTS) exam is the key bedside tool for localizing acute, sustained vertigo: an abnormal head impulse test (a corrective catch-up saccade) plus…
- Management
First step: identify and treat any unstable or emergent central cause before symptomatic treatment, since sedating vestibular suppressants can mask a worsening neurologic exam in a patient having a posterior circulation stroke.
- Complications
Falls and fall-related injury, particularly in older patients with acute or recurrent vertigo, are a major source of morbidity regardless of cause.
- Prognosis
BPPV has an excellent prognosis with repositioning maneuvers, though recurrence is common and repeat maneuvers are often needed.
- Prevention
BPPV recurrence prevention: patients can be taught self-administered repositioning maneuvers (such as Brandt-Daroff exercises) for recurrent episodes at home.
Read the whole article
Subscribing to Internal Medicine opens every article, the full question bank and MedBrain, on the web, iPhone and Android.
Related articles
- Meniere disease
Meniere disease is a chronic inner-ear disorder linked to endolymphatic hydrops, causing recurrent episodic vertigo with fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Diagnosis is clinical, confirmed by audiometry; acute attacks are treated with antiemetics, and prevention relies on a low-salt diet (<2 g sodium/day) and diuretics.
- Vestibular migraine
Vestibular migraine is a common cause of recurrent episodic vertigo in patients with a personal history of migraine, diagnosed clinically by ICHD-3 criteria after excluding Meniere disease and central causes; acute attacks are treated like migraine with NSAIDs, antiemetics, and triptans, with prophylaxis mirroring standard migraine prevention.
- Cerebellar stroke
Cerebellar stroke, ischemic or hemorrhagic infarction of the cerebellum, presents with vertigo, truncal ataxia, dysarthria, and limb incoordination and is diagnosed with brain MRI when CT is falsely reassuring. Its defining danger is delayed swelling that compresses the brainstem and fourth ventricle, which is treated with emergent decompressive suboccipital craniectomy.
- Basilar artery occlusion
Basilar artery occlusion is a posterior circulation large-vessel stroke that threatens the brainstem, cerebellum, and thalami, presenting with rapidly progressive quadriparesis, cranial nerve palsies, and impaired consciousness, up to locked-in syndrome or coma. Diagnosis requires urgent CT angiography, and management is emergent reperfusion with IV alteplase followed by mechanical thrombectomy in eligible patients.
- Migraine headache
Migraine is a primary episodic headache disorder diagnosed by ICHD-3 clinical criteria (recurrent attacks, 4-72 hours, pulsatile/unilateral pain with nausea or photophobia/phonophobia). First-line acute treatment is an NSAID or oral triptan started early in the attack; prevention with a beta-blocker, topiramate, or CGRP-targeted therapy is added once attacks are frequent or disabling.
- Ischemic stroke
Ischemic stroke is sudden focal neurologic deficit from arterial occlusion confirmed by infarction on neuroimaging. Diagnosis relies on urgent noncontrast head CT to exclude hemorrhage; treatment is IV alteplase within 4.5 hours and mechanical thrombectomy for large-vessel occlusion within an extended window, followed by antiplatelet therapy and risk-factor control.