Vertigo Disease Background

Introduction

Epidemiology

Vertigo can occur throughout life, but its incidence increases with advancing age. Females are affected more frequently than males. Benign paroxysmal positional vertigo (BPPV) most commonly begins between the fifth and seventh decades of life. Meniere’s disease is often seen in adults aged 40-60 years. White people of European descent are more affected than Black populations. Vestibular neuritis is relatively uncommon, with an incidence of about 3.5 cases per 100,000 people. This usually occurs in individuals aged 30–60 years, with peak incidence between 40 and 50 years. Males and females are affected equally.

Population-based studies show that dizziness and vertigo are common worldwide, with a 30% lifetime prevalence of moderate to severe symptoms in German adults, a 48% 12-month prevalence reported in France, a 35% 5-year prevalence of vestibular dysfunction among U.S. adults aged ≥40 years, and a 3% 1-year prevalence based on Taiwanese medical claims data.

Etiology

Vertigo may be secondary to different causes that may be determined by numerous factors such as timing, duration, aggravating conditions, and associated symptoms.

Timing and Duration

Vertigo can be categorized based on its duration. Episodes lasting only a few seconds are often seen in late stages of acute vestibular neuronitis and Meniere’s disease. When vertigo persists for several seconds to a few minutes, it is commonly associated with benign paroxysmal positional vertigo (BPPV), perilymphatic fistula, or vestibular paroxysmia. Episodes lasting from minutes up to one hour may indicate a posterior transient ischemic attack (TIA) or perilymphatic fistula. Vertigo that continues for several hours is frequently linked to Meniere’s disease, and perilymphatic fistula due to trauma or surgery, migraine, or acoustic neuroma. If symptoms last for days, possible causes include early acute vestibular neuronitis, stroke, migraine, or multiple sclerosis. Vertigo lasting for weeks without improvement is often considered psychogenic in origin.

Provoking or Aggravating Factors

Provoking or aggravating factors can help identify the underlying cause of vertigo. Changes in head position are commonly associated with conditions such as acute labyrinthitis, benign paroxysmal positional vertigo, cerebellopontine angle tumors, multiple sclerosis, perilymphatic fistula, Meniere’s disease, and acute vestibular neuronitis. A recent upper respiratory viral infection may point to acute vestibular neuronitis or acute labyrinthitis. Stress is often linked to migraines as well as psychiatric or psychological causes of vertigo. In immunosuppressed individuals, herpes zoster oticus should be considered. Vertigo triggered by changes in ear pressure, trauma, excessive straining, or exposure to loud noises is suggestive of a perilymphatic fistula.

Severity of Vertigo Over Time

The severity of vertigo over time can provide important clues to its underlying cause. In acute vestibular neuronitis, initial symptoms are typically severe at onset but gradually lessen over the following. In Meniere’s disease, vertigo attacks often occur in clusters initially, though the frequency of episodes may decrease over time. Vertigo associated with psychological causes tends to remain relatively constant for several weeks.

Pathophysiology

Dizziness and vertigo affect balance, causing the brain to rely on signals from the inner ear, eyes, and body position. These signals are processed by the central nervous system to control movement. When these pathways are affected, especially in older adults, dizziness or vertigo can occur and may be caused by neurological, cardiovascular, visual, vestibular, or psychological problems.

Benign Paroxysmal Positional Vertigo (BPPV)

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Risk Factors

Risk factors associated with vertigo include stress or anxiety, high or low blood pressure, osteoporosis, a history of head trauma or falls, orthostatic hypotension, cerebrovascular disease or stroke, vitamin D deficiency, smoking, obstructive sleep apnea, migraine, cervical spondylosis, and low hemoglobin levels. Additional risk factors for benign paroxysmal positional vertigo include a history of head trauma or prolonged recumbent position, inner ear disease, migraine, and disorders of calcium metabolism. For Meniere’s disease, other associated factors include the history of head or ear trauma, allergies, obesity, autoimmune disorders, and metabolic disorders (eg hypertension, diabetes, dyslipidemia).

Classification

Central Vertigo

Central vertigo is a vertigo originating from the central nervous system (brainstem or cerebellum). This is uncommon but more serious and should be ruled out immediately.

Distinctive Features

Distinctive features of central vertigo include either gradual or sudden onset with generally mild intensity that can last for weeks to months, although in vascular causes it may last only seconds to minutes. Associated neurological findings are always present. There are usually no auditory findings except for stroke involving the anterior inferior cerebellar artery. Dizzy spells are described as lightheadedness and severe imbalance in which the patient cannot stand still or walk. The characteristics of nystagmus in central vertigo may be horizontal, rotary, or vertical direction; short latency; sustained duration; mild intensity; non-fatigable; and not suppressed by visual fixation. The Head Impulse, Nystagmus, and Test of Skew (HINTS) test reveals a negative head impulse test, a central characteristic of nystagmus, and a positive test of skew.

Common Causes

Common causes of central vertigo are migrainous vertigo, cerebrovascular disease (eg TIA, stroke), and multiple sclerosis.

Please see separate disease management charts for further information.

Peripheral Vertigo

Peripheral vertigo is a vertigo originating from the labyrinth or vestibular nerve.

Distinctive Features

Distinctive features of peripheral vertigo include sudden onset and severe intensity. Episodes usually last for seconds to minutes but occasionally from hours to days and occur intermittently. There is an absence of associated neurologic findings. Auditory symptoms (eg hearing loss, tinnitus) may be present. Dizziness is described as “rotating surroundings" or “the patient is spinning.” There is a mild imbalance that the patient can still stand steadily or walk. The characteristics of nystagmus in peripheral vertigo include either horizontal or upbeat-torsional nystagmus that beats in a unilateral direction even if the eye gazes to the left or right; long latency; transient duration; mild to severe intensity; fatigability; and suppression by visual fixation. The HINTS test reveals a positive head impulse test, peripheral characteristics of nystagmus, and a negative test of skew.

Common Causes Differentiated by Duration of Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo that occurs for a few seconds. Meniere’s disease has vertigo that lasts from minutes to hours. Acute vestibular dysfunction has vertigo that can be felt from hours to days, such as acute vestibular neuronitis and acute labyrinthitis.

Other Peripheral Causes

Other peripheral causes include superior canal dehiscence (SCD), cholesteatoma, herpes zoster oticus, otosclerosis, perilymphatic fistula, and vestibular paroxysmia.

Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo is a sudden or rapid spinning sensation due to a change of head position relative to gravity. This usually occurs when rolling over in bed or when tilting the head to look upward or bending forward.

Types of Benign Paroxysmal Positional Vertigo

Posterior Semicircular Canal BPPV (Posterior Canal BPPV)

Posterior semicircular canal BPPV is the most common type of benign paroxysmal positional vertigo that is believed to be due to the trapping of debris of fragmented endolymph particles in the posterior canal.

Lateral Semicircular Canal BPPV (Horizontal Canal BPPV)

Lateral semicircular canal BPPV is a less common type of benign paroxysmal positional vertigo that may be due to the same etiology as posterior canal BPPV, but the pathophysiology is still not clear.

Anterior Canal BPPV

Anterior canal BPPV is usually transitory and results from “canal switching” that occurs in the course of treating other more common forms of benign paroxysmal positional vertigo.

Meniere’s Disease

Meniere’s disease is also called endolymphatic hydrops. There are discrete episodic attacks characterized by sustained vertigo (lasting at least 20 minutes), fluctuating sensorineural hearing loss (confirmed by audiometric testing), low-pitch tinnitus, and aural fullness.

Acute Vestibular Dysfunction

Acute vestibular dysfunction is a sudden, unanticipated, severe vertigo with a subjective sensation of rotational motion that is commonly preceded by a viral prodrome. This is composed of two disease entities: Acute vestibular neuronitis and acute labyrinthitis.

Acute Vestibular Neuronitis

Acute vestibular neuronitis is an inflammation of the vestibular nerve usually caused by the herpes virus. There is spontaneous, unidirectional, horizontal nystagmus in which the fast phase beats away from the affected ear. On Romberg test, the patient tends to fall towards the affected side. There is an inability to maintain visual fixation with rapid turning of the head toward the side of the lesion.

Acute Labyrinthitis

Acute labyrinthitis is an infection of the inner ear that causes inflammation of the membranous labyrinth and damage to the vestibular and auditory end organs. This may be caused by a viral or bacterial infection. Vertigo is severe, often incapacitating, and with sudden onset. In many cases, the primary presenting symptom is hearing loss, not associated with ear fullness seen in Meniere’s disease. It is important to ask about hearing loss since this does not occur with benign paroxysmal positional vertigo or vestibular neuronitis. The patient also experiences sudden unilateral loss of vestibular function. Tinnitus may be present.