Vertigo

Vertigo (from the Latin vertō — “to turn, to spin”) is a form of dizziness characterized by the illusion or false sensation that either the body or surrounding objects are moving. Patients often describe this condition as spinning, falling, swaying, or rocking.

It is critically important to distinguish true vertigo from other types of dizziness, such as lightheadedness, presyncope, or imbalance. Vertigo is almost always a symptom of dysfunction within the vestibular system, which may be localized either peripherally (inner ear, vestibular nerve) or centrally (brainstem, cerebellum).

Aetiology and Pathophysiology

Normal balance is maintained through the coordinated function of three systems: vestibular, visual, and proprioceptive (muscles and joints). Vertigo develops when the brain receives conflicting or asymmetric input from the vestibular receptors of the left and right ears, or when vestibular signals are incongruent with information from other sensory systems.

By location, vertigo is classified into:

• Peripheral vertigo:
  • Description: Accounts for approximately 80–90 % of all cases. Origin: The inner ear or vestibular nerve.
  • Etiologies: Benign paroxysmal positional vertigo (BPPV) — the most common cause; Ménière’s disease; vestibular neuritis; labyrinthitis.
  • Clinical features: The condition typically presents with intense, rotational episodes; often accompanied by marked nausea, vomiting, and diaphoresis. It is also frequently associated with auditory symptoms such as hearing loss and tinnitus.
• Central vertigo:
  • Description: Originates in the brainstem or cerebellum. This form is more serious and potentially life-threatening.
  • Etiologies: Stroke in the vertebrobasilar territory; multiple sclerosis; tumors of the cerebellopontine angle; vestibular migraine.
  • Clinical features: Dizziness tends to be less intense but more persistent; more often described as imbalance rather than spinning. Commonly accompanied by other neurological signs: diplopia, dysarthria, limb weakness, and ataxia.

Clinical Significance

The primary goal in evaluating a patient with vertigo is to differentiate benign peripheral causes from dangerous central ones. Diagnosis relies on a detailed medical history (including duration, frequency of episodes, and triggers), neurological examination, and specialized tests.

A key component of the physical exam is the assessment of nystagmus, or involuntary oscillatory eye movements. Nystagmus features — such as direction, fatigability, and suppression with gaze fixation — help localize the lesion. BPPV is diagnosed using the Dix — Hallpike maneuver. In emergency settings, the HINTS exam (Head Impulse-Nystagmus-Test for Skew) is used to differentiate stroke from vestibular neuritis.

Management is linked entirely to the underlying cause: BPPV may be effectively treated with repositioning maneuvers (e.g., Epley maneuver). Vestibular neuritis is managed with corticosteroids and vestibular rehabilitation exercises. Central vertigo requires targeted treatment of the primary pathology (e.g., thrombolysis in stroke).

Differential Diagnosis

True vertigo must be distinguished from other conditions that patients may also describe as “dizziness”. They may include presyncope, a sensation of “fading out” or visual dimming, often due to hypotension; imbalance, as unsteadiness or gait instability, common in older adults; and nonspecific or psychogenic dizziness described as “lightheadedness” or “foggy-headedness”. The presence of any focal neurological signs, vertical nystagmus, or severe postural instability preventing the patient from standing is a red flag. Such findings warrant urgent hospitalization and neuroimaging (CT/MRI) to rule out stroke.