The first and most important step in evaluating a patient with vertigo is to attempt to distinguish vertigo of central origin from vertigo of peripheral origin because the management of central vertigo (brain imaging, hospital admission) is very different from the management of peripheral vertigo (symptomatic treatment, outpatient referral).
Differences Between Central and Peripheral Vertigo
|
Peripheral Vertigo |
Central Vertigo |
| Percentage of cases: |
80% |
20% |
| Patient demographic: |
Specific risk factors absent |
Specific risk factors present:
- For stroke: older age, hypertension, smoking, diabetes mellitus
- For multiple sclerosis: young Caucasian female from a temperate climate
- For brain tumor: history of cancer
|
| Site of lesion: |
Peripheral
- Vestibular apparatus
- Vestibular nerve
|
Central
|
| Classic toxin: |
Aminoglycosides |
Phenytoin |
| Most common causes: |
- Benign paroxysmal positional vertigo (BPPV)
- Vestibular neuritis
- Labyrinthitis
- Ménière disease
|
- Vertebrobasilar (posterior circulation) ischemia
- Multiple sclerosis
- Posterior fossa or cerebellopontine angle tumors
- Basilar migraine
|
| Accompanying neurologic symptoms: |
Ear symptoms
- Sensorineural hearing loss
- Tinnitus
- Ear pain or fullness
|
CNS symptoms
- Brainstem: headache, dysarthria, diplopia, focal weakness or sensory loss in the face or limbs
- Cerebellum: incoordination (limb ataxia with intention tremor and terminal dysmetria on the ipsilateral side)
|
| Nystagmus |
Features are benign:
- Latent (delayed) onset
- Fatigable (nystagmus abates when the provocative position is held for a long time)
- Inhibited by fixation of gaze
|
Features are malignant:
- Immediate onset
- Non-fatigable
- Not inhibited by fixation of gaze
|
| Workup & Disposition |
Conservative:
- Symptomatic treatment (vestibular rehabilitation, canalith repositioning maneuvers, antiemetics, vestibular sedatives)
- Outpatient referral
- No hospitalization
|
Aggressive:
- MRI of the brain (to look for strokes, tumors or evidence of demyelination)
- CT angiogram or MRA of the head and neck (to look for vertebral artery dissection)
- Hospitalization
|
References
- Neurological Differential Diagnosis (2005)
- Symptoms to diagnosis, 3e (2014)
- Clinical Neurology, 9e (2015)
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