Vertigo
Differential Diagnosis
Common Diagnoses
- Benign Positional Vertigo
- Vestibular Migraine
- Ménière’s Disease
- Vestibular Neuritis
- Eustachian Tube (ET) Dysfunction (Causes Mild Vertigo)
Occasional Diagnoses
- Chronic Otitis Media
- Drugs: Salicylates, Quinine, Aminoglycosides
- Acute Alcohol Intoxication (Common, but Unlikely to Present to the GP)
- Neurological Conditions (e.g. CVA, Multiple Sclerosis [MS], Syringobulbia, Cerebellar, Tumours)
- Epilepsy
Rare Diagnoses
- Earwax (Common Problem but Rare Cause of Vertigo)
- Syphilis
- Acoustic Neuroma
- Nasopharyngeal Carcinoma
- Post-Traumatic
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Benign Positional | Vestibular Migraine | Ménière’s | Vestibular Neuritis | ET Dysfunction | |
|---|---|---|---|---|---|
| Tinnitus | No | No | Yes | Possible | Possible |
| Rapid Onset, Severe | Possible | Possible | Yes | Possible | No |
| Momentary | Yes | No | No | No | Possible |
| Associated Viral Illness | No | No | No | Yes | Possible |
| Recurrent | Yes | Yes | Yes | No | No |
Possible Investigations
- There are no investigations likely to be performed in primary care. Referral might lead to a number of secondary care tests, such as audiometry for cochlear function; electronystagmography, calorimetry and brainstem-evoked responses to assess vestibular function; CT or MRI scan for possible neurological conditions; EEG for suspected epilepsy; lumbar puncture in possible MS; and syphilis serology if syphilis is suspected.
Top Tips
- Take a careful history – the patient may use the term ‘vertigo’ inaccurately, or describe true ‘vertigo’ as light-headedness. The diagnostic possibilities for vague dizziness and true vertigo are quite different.
- The vast majority of cases seen in primary care are benign positional vertigo, vestibular migraine, Ménière’s disease or viral neuritis.
- Ménière’s disease tends to be over-diagnosed. It comprises violent paroxysms of vertigo lasting for several hours, associated with deafness and tinnitus, often necessitating urgent attention because of prostration and vomiting.
- Benign positional vertigo is usually easily diagnosed by the history – the patient experiences vertigo lasting only for a few seconds, classically on turning over in bed.
- Vestibular migraine is under-diagnosed. Consider it in any case of recurrent vertigo – enquire about headache before, during or after the vertigo.
Red Flags
- The patient who has chronic otitis media and then develops vertigo probably has significant disease – especially if the fistula sign is positive (putting pressure on the external ear canal by forcibly occluding the external auditory meatus with a finger causes vertigo). Refer urgently.
- Young or middle-aged patients with atypical, episodic vertigo who have other, diffuse and transient neurological symptoms may have MS.
- Loss of consciousness with vertigo suggests epilepsy.
- An acoustic neuroma can cause quite mild vertigo. Consider this possibility if the patient also has a unilateral sensorineural deafness and tinnitus.
- A neurological cause such as a stroke is suggested by any CNS symptoms or signs; a new type of headache, especially occipital; acute deafness (otherwise unexplained); or vertical nystagmus.