Vertigo
Vertigo is an illusion of movement of either the patient or his or her environment. This is both visual and positional. Associated nausea or vomiting are common and, in its acute form, it is a severe and completely disabling symptom. It must be distinguished from ‘light-headedness’ (see section on Dizziness).
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.