What is Vertigo?

Vertigo is the illusion of movement — specifically a spinning or rotational sensation either of the patient or their surroundings — in the absence of actual movement. It is distinct from dizziness (lightheadedness or pre-syncope) and must be differentiated clinically. Vertigo arises from asymmetric vestibular input reaching the brain.

Vertigo is broadly classified as peripheral (arising from the inner ear or vestibular nerve) or central (arising from the brain — brainstem or cerebellum). Central causes are potentially more serious and require careful clinical differentiation.

Common Causes

• Benign Paroxysmal Positional Vertigo (BPPV) — most common cause of true vertigo
• Vestibular neuritis (acute prolonged vertigo, often post-viral)
• Meniere's disease (recurrent vertigo with hearing loss and tinnitus)
• Migraine-associated vertigo / vestibular migraine
• Posterior fossa stroke or TIA
• Head injury

Bhattacharyya N, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1–S47. doi:10.1177/0194599816689667 — BPPV is the most common cause of vertigo; canalith repositioning (Epley maneuver) is effective first-line treatment.

HINTS Examination (to exclude stroke in acute vestibular syndrome)

In patients presenting with continuous acute vertigo, the HINTS (Head Impulse, Nystagmus, Test of Skew) examination is more sensitive than early MRI for detecting posterior fossa stroke:

• Head Impulse: normal (no corrective saccade) → CENTRAL (stroke)
• Nystagmus: direction-changing gaze-evoked nystagmus → CENTRAL
• Test of Skew: vertical skew deviation present → CENTRAL