Vertigo classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Classification

Distinguish cause of vertigo based on:

1. Time course
2. Duration
3. Recurrence

Lasting a day or longer

• Vestibular neuronitis

1. Onset over hours, peaks in first day, improves within days
2. May recur episodically for weeks to months

• Vertebrobasilar ischemia with labyrinth infarct

1. Abrupt onset, improves within 1 week
2. Symptomss resolve within weeks to months

• Brain-stem stroke: usually other symptoms vertebrobasilar ischemia
• Inferior cerebellar infarct/bleed: similar symptoms/time course to vestibular neuritis
• Multiple sclerosis: vestibular symptoms evolve over hours to days

Lasting minutes to hours

• Meniere’s disease: episodic/recurrent
• Vertebrobasilar transient ischemic attack (TIA): typically lasts < 30 minutes, may recur
• Migraine Headache: episodic/recurrent
• Perilymph fistula: episodic; precipitated by exertional straining or change in air pressure

Lasting seconds

• Benign paroxysmal positional vertigo (BPPV): usually lasts < 1 minute

Alternative anatomic classification: central vs. peripheral

Central (20%):

• Caused by damage to vestibular structures in brainstem or cerebellum
• Associated with other brainstem deficits
• Vertigo and nystagmus can be bidirectional or vertical
• Vertebrobasilar insufficiency:

1. Accounts for ½ of central causes
2. Brainstem or cerebellar territory (anterior inferior cerebellar artery (AICA), posterior inferior cerebellar artery (PICA)) -> transient ischemic #ttack (TIA) or cerebrovascular accident (CVA)
3. Associated diplopia, dysarthria, dysphagia, hemiparesis, etc.
4. Cerebellar infarct may present with isolated vertigo
5. Can have pontine lacunes, labyrinthine infarcts

• Multiple sclerosis: associated brainstem symptoms may be subtle (facial numbness)

1. Vertiginous symptoms may be sudden, transient, recurrent or persistent

• Migraine: vertigo precedes headache and may last afterward

1. Atypical form of migraine with aura -> may respond to migraine therapy

• Drugs

1. Sedatives, anticonvulsants may cause central vertigo in high/excess doses
2. Anticonvulsants in prescription doses may cause nystagmus (phenytoin, carbamazepine)

Peripheral (80%):

• Caused by damage to vestibular labyrinth, vestibular nerve
• Associated tinnitus, hearing loss if auditory component of CN VIII affected
• Vertigo and nystagmus are unidirectional, and not vertical
• BPPV

1. Accounts for more than ½ of cases peripheral vestibular dysfunction
2. Common in the elderly (patients usually > 60)
3. Episodes of sudden onset, short duration -> condition often remits in 6 months
4. Mechanism = stimulation of labyrinth by debris in posterior semicircular canal

• Vestibular neuronitis

1. Accounts for ¼ of cases peripheral vestibular dysfunction
2. Isolated vertigo due to viral infection involving labyrinth (after URI)

• Acute labyrinthitis

1. Viral involvement of cochlea and labyrinth after upper respiratory infection (URI)
2. Vertigo associated with tinnitus and hearing loss
3. symtpoms resolve completely within 3-6 weeks

• Meniere’s disease

1. Idiopathic endolymphatic hydrops -> damage to hair cells
2. Tinnitus, ear pressure and hearing loss associated with vertigo
3. Paroxysmal episodes lasting minutes to hours
4. Frequency of episodes waxes and wanes over time
5. Hearing loss can become permanent

• Acoustic neuroma

1. Benign tumor, but can cause brainstem compression if unprescribed
2. Retrocochlear hearing loss, tinnitus, vague dizziness
3. Very gradual symptom onset with progressive asymmetric hearing loss
4. Vertigo not prominent because gradual time course allows central nervous system adaptation

• Ototoxins: hearing impairment usually >> vestibular symptoms

1. Gentamicin, streptamicin most injurious to vestibular portion of CN VIII

References

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