Vertigo
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Direct answer
An illusion of movement — the room or the patient spinning — is what the clinician means by true vertigo, and the first task is separating peripheral (labyrinth and vestibular nerve) from central (brainstem and cerebellum) causes. Peripheral vertigo, dominated by benign paroxysmal positional vertigo, vestibular neuritis and Meniere disease, comes in episodes with latency, fatigability, horizontal-torsional nystagmus and violent nausea. Central vertigo is continuous, lacks latency and fatigability, and shows vertical or direction-changing nystagmus with brainstem signs — a stroke until proven otherwise. BPPV, the single commonest cause, is cured at the bedside by the Epley repositioning manoeuvre after a positive Dix-Hallpike test.
What you must remember
- BPPV: brief (under a minute) rotatory vertigo on turning in bed or looking up; posterior canal in the large majority; diagnosed by Dix-Hallpike, cured by Epley manoeuvre — no drugs.
- Peripheral nystagmus features: short latency, fatigues on repetition, horizontal-torsional, suppressed by visual fixation; central nystagmus is the opposite on every count.
- Vestibular neuritis: hours-to-days of constant vertigo and unsteadiness with normal hearing; labyrinthitis adds sensorineural hearing loss to the same picture.
- Downbeat or purely vertical nystagmus, skew deviation, or direction-changing nystagmus on gaze suggests a central lesion — image urgently.
- HINTS exam in acute continuous vertigo: normal head impulse test, direction-changing gaze-evoked nystagmus and skew deviation point central — more sensitive than early MRI.
- Sudden vertigo with new hearing loss, unilateral tinnitus or facial weakness requires urgent workup, since labyrinthitis, schwannoma and anterior inferior cerebellar artery stroke sit here.
- Any red flag — inability to stand, dysarthria, diplopia, dysphagia, headache, normal head impulse in continuous vertigo — means MRI, not manoeuvres.
Worked example: two patients, one week apart
A 52-year-old woman reports that rolling to the right in bed brings a 20-second spin with nausea; she is fine between spells, and hearing is normal. Sitting her up and laying her head 45 degrees turned to the right (Dix-Hallpike), after a two-second pause you see geotropic-torsional nystagmus with the fast phase beating toward the undermost right ear, fatiguing within half a minute. Repetition weakens it. This is posterior canal BPPV from displaced otoconia; treat her immediately in the clinic with the Epley manoeuvre — sequential head positioning from the provoking side through the contralateral shoulder with the body rolled — and teach home Brandt-Daroff exercises. No medication is indicated; vestibular suppressants actually delay central compensation.
The next patient, a 58-year-old hypertensive man, has been continuously dizzy for a day, vomits, and staggers to his right; he cannot stand unaided. There is no latency or fatigability here. The head impulse test is normal (the bedside paradox — a normal test in continuous vertigo is worrying), nystagmus changes direction on left versus right gaze, and there is subtle dysarthria. This is not neuritis: it is a posterior circulation stroke, and the next step is urgent MRI with diffusion weighting and neurology referral, because early CT can miss posterior fossa ischaemia. The pair of cases teaches the entire topic: episodic positional symptoms with latency answer peripheral disease and manoeuvres; continuous symptoms with normal head impulse or direction-changing nystagmus answer central disease and imaging.
Where students slip
The recurring slips are duration-anchored. Candidates call an all-day spin "BPPV" — BPPV lasts seconds, Meniere disease episodes last tens of minutes to hours, and neuritis lasts days; the duration alone often selects the answer. The second slip is treating BPPV with betahistine or prochlorperazine long-term: the examinable answer is repositioning, with drugs reserved briefly for suppressing acute nausea in neuritis or Meniere disease. The third, and most dangerous, is labelling any vertigo "cervical" or "gastritis-related" in an older patient with vascular risk — the HINTS findings above exist precisely to catch the posterior circulation stroke masquerading as a harmless ear problem.
Frequently asked questions
What is the commonest cause of peripheral vertigo?
Benign paroxysmal positional vertigo, due to otoconial debris usually in the posterior semicircular canal.
How is BPPV diagnosed and treated?
Diagnosed by the Dix-Hallpike manoeuvre showing geotropic torsional nystagmus after brief latency, and treated by the Epley canalith repositioning manoeuvre.
Which nystagmus characteristics suggest a central cause?
Absence of latency, no fatigability, non-suppression by fixation, purely vertical (especially downbeat) or direction-changing gaze-evoked nystagmus.
What does HINTS stand for and which combination is dangerous?
Head Impulse, Nystagmus, Test of Skew; a normal head impulse with direction-changing nystagmus or skew deviation in continuous vertigo points to a central cause.
How do vestibular neuritis and labyrinthitis differ?
Both cause prolonged constant vertigo after a viral illness, but neuritis spares hearing while labyrinthitis adds sensorineural hearing loss and tinnitus.