Vertigo

Overview

Vertigo is a clinical symptom — not a standalone diagnosis — referring to a false sensation of spinning or movement. It commonly arises from dysfunction in the vestibular system (inner ear or CN VIII), and is a frequent complaint in both emergency and primary care settings. This article outlines key causes and distinguishing features, diagnosis and management for final-year medical students.

Definition

• The Illusion of motion (spinning or tilting), usually exacerbated by head movement.
• Distinct from:
  • Presyncope (faintness or light-headedness)
  • Disequilibrium (unsteadiness)
  • Non-specific dizziness

Pathophysiology

• Originates from mismatch or disruption in sensory input between:
  • Vestibular system (labyrinth, semicircular canals)
  • Visual system
  • Proprioception (joint and muscle sensors)
• Key anatomical structures involved:
  • Inner ear
  • Vestibulocochlear nerve (CN VIII)
  • Brainstem and cerebellum

Common Causes

Motion Sickness

• Cause: Sensory mismatch between vestibular and visual cues.
• Presentation: Nausea, dizziness, cold sweats, pallor.
• Triggers: Travel (cars, boats, planes), simulators, VR.

Labyrinthitis & Vestibular Neuritis

• Cause: Viral or bacterial infection; post-viral inflammation; metabolic issues (e.g. hypoglycaemia).
• Distinction:
  • Labyrinthitis: Involves both vestibular system and cochlea → vertigo + hearing loss
  • Vestibular neuritis: Involves vestibular nerve only → vertigo without hearing loss
• Features:
  • Sudden, severe dizziness
  • Nausea, vomiting
  • Gait imbalance

Ménière’s Syndrome

• Cause: Excess endolymphatic fluid → distention of labyrinth
• Features:
  • Recurrent episodes (lasting minutes to hours)
  • Dizziness, nausea, vomiting
  • Tinnitus + fluctuating sensorineural hearing loss
• Triggers: High-salt intake, stress, alcohol
• Diagnosis: Clinical + audiometry

Benign Paroxysmal Positional Vertigo (BPPV)

• Cause: Dislodged otoliths (calcium carbonate crystals) in semicircular canals
• Triggers: Head movements (rolling over, looking up)
• Features:
  • Sudden brief episodes (<1 min)
  • Vertigo triggered by position changes
  • No hearing loss or tinnitus
• Diagnosis: Dix-Hallpike manoeuvre
• Treatment: Epley repositioning manoeuvre

Other Causes

• Drugs: Alcohol, aminoglycosides, anticonvulsants
• Brainstem Lesions: Stroke, multiple sclerosis
• Migraine-associated Vertigo
• Elderly: Vascular insufficiency to inner ear

Investigations

• Clinical manoeuvres: Dix-Hallpike, head impulse test
• Audiometry: Assess for concurrent hearing loss
• Imaging: MRI brainstem/cerebellum if red flags (persistent, focal deficits, ALOC)
• Bloods: Rule out metabolic or infective causes

Management

• BPPV: Epley or Semont manoeuvre
• Ménière’s: Salt restriction, diuretics, betahistine
• Labyrinthitis/Vestibular neuritis: Anti-emetics (prochlorperazine), vestibular rehab
• Motion sickness: Antihistamines (promethazine), scopolamine patches
• Psychogenic vertigo: CBT, SSRIs

Summary

Vertigo is a key symptom indicating vestibular dysfunction, with causes ranging from BPPV and Ménière’s disease to infections like labyrinthitis and neuritis. Accurate history and bedside tests (e.g. Dix-Hallpike) are crucial for diagnosis. For a broader context, see our Nervous System Overview.