Vertigo and Vestibular Disorders
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Direct answer
Vertigo is solved by timing and triggers before anything else: seconds of positional spinning suggests benign paroxysmal positional vertigo, minutes to hours of spontaneous episodes suggest Meniere disease or vestibular migraine, and continuous days suggest vestibular neuritis, labyrinthitis or stroke. Benign paroxysmal positional vertigo is diagnosed by the Dix-Hallpike manoeuvre and cured by the Epley manoeuvre; the HINTS examination separates peripheral acute vestibular syndromes from posterior circulation stroke at the bedside; vestibular neuritis recovers better with a short course of corticosteroids, and vestibular suppressants must stop within days.
What you must remember
- The temporal framework is the diagnosis: positional seconds (BPPV), spontaneous minutes to hours (Meniere, vestibular migraine), continuous days (neuritis, labyrinthitis, stroke).
- Benign paroxysmal positional vertigo: posterior canal in most; Dix-Hallpike provokes latency-onset, fatigable, upbeat torsional nystagmus with vertigo; the Epley manoeuvre cures; the horizontal canal variant is tested by the supine roll and treated with the barbecue manoeuvre.
- HINTS in the acute vestibular syndrome: a normal head impulse test, direction-changing gaze-evoked nystagmus and skew deviation each point central — and carry more weight than an early normal MRI.
- Vestibular neuritis: hours-to-days of continuous rotatory vertigo with unidirectional horizontal-torsional nystagmus, positive head impulse and no hearing loss; a short oral corticosteroid course improves recovery, antivirals do not. Labyrinthitis adds hearing loss, and sudden sensorineural loss with vertigo is an otological emergency.
- Meniere disease: recurrent spontaneous vertigo of twenty minutes to twelve hours with fluctuating low-frequency sensorineural hearing loss, tinnitus and aural fullness; managed with salt restriction, betahistine and diuretics, escalating to intratympanic corticosteroids or gentamicin.
- Vestibular migraine is the commonest cause of spontaneous episodic vertigo: motion sensitivity, photophobia and migraine history, treated with migraine preventives. Red flags demanding imaging are central signs on HINTS, vertical nystagmus, new deafness with brainstem findings, inability to stand, headache or neck pain, and vascular risk with a normal head impulse.
- Symptomatic suppressants — prochlorperazine, cinnarizine, promethazine — are for the first two to three days only, because they delay central compensation; thereafter, vestibular rehabilitation.
Common confusion
The bedside battleground is peripheral versus central nystagmus: peripheral nystagmus is horizontal-torsional, unidirectional, suppressed by fixation and worse gazing toward the fast phase; central nystagmus may be pure vertical or torsional, changes direction with gaze, ignores fixation and brings brainstem signs. Orthostatic dizziness is light-headedness on standing, not spinning, and is a blood pressure question. Persistent postural-perceptual dizziness is chronic non-spinning dizziness with motion sensitivity and a normal examination — a positive diagnosis treated with rehabilitation, not exclusion.
Exam-focused takeaway
Learn the manoeuvres as answers: Dix-Hallpike diagnoses posterior canal BPPV, Epley treats it, the supine roll tests the horizontal canal, and HINTS triages the acute vestibular syndrome. Steroids for neuritis and a hard stop on suppressants after three days are the therapy marks. The Meniere window — twenty minutes to twelve hours with fluctuating low-frequency loss — is the arithmetic examiners quote verbatim.
Frequently asked questions
How is benign paroxysmal positional vertigo diagnosed and treated?
Dix-Hallpike provokes the characteristic upbeat torsional nystagmus, and the Epley manoeuvre repositions the displaced canaliths, usually curing in one or two sessions.
What is the HINTS examination?
Head impulse, nystagmus and test of skew: a normal head impulse, direction-changing gaze-evoked nystagmus or skew deviation indicates a central cause.
Are corticosteroids useful in vestibular neuritis?
Yes — a short tapering oral course improves vestibular recovery; antivirals alone do not.
How long should vestibular suppressants be used?
No more than about three days, since ongoing suppression delays central compensation and prolongs disability.
What are the red flags in vertigo?
Central signs on HINTS, vertical nystagmus, new deafness with brainstem findings, inability to stand, headache or neck pain, and vascular risk.