Types of Dizziness

Distinguishing Central vs. Peripheral Vertigo

Characteristic	Peripheral	Central
Onset	Sudden	Gradual
Intensity	Severe	Mild
Duration	Minutes	Weeks
Timing	Intermittent	Continuous
Nystagmus	Horizontal	Vertical, bidirectional
Exacerbation with head movement	+	–
Auditory symptoms	+	–
Neurological findings	–	+

Causes of Vertigo

Characteristics of common causes of vertigo

Cause	Mechanism	Onset	Symptoms	Findings
Peripheral
BPPV	Otolith	Brief, positional episodes	Nausea, vomiting, absent auditory symptoms.	Dix-Hallpike positive
Vestibular neuronitis	Viral, post-viral inflammation of vestibular portion of CNVIII	Acute and severe, subsiding over days.	Nausea, vomiting, absent auditory symptoms.	Head thrust abnormal
Meniere	Endolymphatic hydrops	Recurrent, lasting hours	Tinnitus, hearing loss.	SNHL
Central
Vertebrobasilar insufficiency	Atherosclerosis (vascular risk factors)	Acute onset, recurrent episodes if TIA	Headache, gait impairment, diplopia, absent auditory symptoms.	Neurologic deficits
Cerebellar stroke	Atherosclerosis (vascular risk factors)	Acute and severe	Headache, dysphagia, gait impairment	Dysmetria, dysdiadochokinesia, ataxia, CN palsy
Brainstem stroke	Atherosclerosis (vascular risk factors), dissection	Acute and severe	Dysphagia, dysphonia, gait impairment, sensory disturbances	Loss of pain/temperature on ipsilateral face, contralateral body, palatal/pharyngeal paralysis
MS	Demyelination	Subacute onset	History of other, variable symptoms	INO

History

• Onset, duration, timing, severity, exacerbating factors
• Vascular risk factors: age, male, HTN, CAD, DM, atrial fibrillation
• Vestibulotoxic medications: aminoglycosides, AED

Key Physical Examination Findings

• VS: Presence of hypotension suggests presyncope
• Head: Examine for evidence of trauma
• Neck: Auscultate for carotid bruit
• Ear: Effusion or perforation suggests peripheral process (possible perilymphatic fistula)
• Eye: Examine for pupillary defects (CNIII), papilledema, extraoccular muscles
• Neuro: Cerebellar testing

Positional Testing

Dix-Hallpike

Turn head 45°

Upright sitting → supine (head overhanging bed)

Positive: nystagmus + symptoms on one side

Roll

Supine

Turn head 90°

Positive: nystagmus + symptoms on both sides, more severe on affected

HINTS¹

Normal head impulse, direction-changing nystagmus, or skew deviation suggests stroke.

Head impulse

Focus on examiner’s nose

Rapidly turn head 10° in horizontal plan

Presence of corrective saccade suggests defect of peripheral vestibular nerve

Nystagmus

Peripheral: Horizontal, unidirectional. Increases on gaze in direction of fast phase (decreases or resolves opposite)

Central: Direction changing

Skew deviation

Cross cover

Presence of vertical disconjugate gaze suggests brainstem dysfunction

HINTS Gallery

Labs

• Glucose
• CBC/Chemistry
• ECG

Imaging

• Warranted if findings concerning for central process
• MRI preferred

Management

Specific etiologies

Vestibular neuronitis: steroids

Meniere: dietary changes

BPPV: canalith repositioning

Symptomatic relief

Promethazine (Phenergan) 12.5-25mg PO

Ondansetron (Zofran) 4mg IV

Lorazepam (Ativan) 1-2mg PO/IV

Meclizine (Antivert) 25mg PO q6-8h PRN

References

1. Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y.-H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke; a journal of cerebral circulation, 40(11), 3504–3510. doi:10.1161/STROKEAHA.109.551234
2. Chang, A., & Olshaker, J. (2013). Dizziness and Vertigo. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 162-169). Elsevier Health Sciences.