Vertigo
Vertigo is a symptom, not a diagnosis. It refers to a false sensation of movement (spinning or rotation) of the person or their surroundings in the absence of any actual physical movement. In contrast, dizziness is a perception of disturbed or impaired spatial orientation, but there is no false sense of motion.
This updated UKMLA guide to vertigo covers central and peripheral causes and key differentiating features based on HINTS examination.
Central Vertigo
Key causes:
- Vestibular migraine – most common central cause
- Posterior circulation stroke / TIA
- Cerebellar tumour
- Acoustic neuroma (vestibular schwannoma)
Peripheral Vertigo
Key causes:
High-yield comparison table (see the corresponding articles for more information):
| Feature | BPPV | Meniere’s disease | Vestibular neuronitis | Labyrinthitis |
|---|---|---|---|---|
| Core mechanism | Displaced otoconia in semi-circular canals | Inflammation of the vestibular portion of CN VIII | Inflammation of the labyrinth (affecting both vestibular and cochlear structures) | Endolymphatic hydrops |
| Course | Recurrent attacks, may resolve spontaneously | Recurrent attacks + progressively worsen over time | Singe acute episode | Singe acute episode |
| Trigger | Change in head position | Spontaneous | Spontaneous | Spontaneous |
| Vertigo duration | <1 min | 20 min to 24 hours | Days to weeks | Days to weeks |
| Cochlear symptoms (hearing loss, tinnitus) | Absent | Present | Absent | Present |
| Diagnosis | Dix-Hallpike test | Clinical diagnosis + audiometry | Clinical diagnosis | Clinical diagnosis |
| Management | Epley manoeuvre and other repositioning manoeuvres +/- vestibular rehabilitation | Short-term vestibular suppressants +/- betahistine | Short-term vestibular suppressants +/- vestibular rehabilitation | Short-term vestibular suppressants +/- vestibular rehabilitation |
HINTS Examination
HINTS examination is a set of clinical tests used to identify central causes of vertigo, which is more serious and often warrants urgent further assessment.
| HINTS component | How to do | Peripheral vertigo finding | Central vertigo finding |
|---|---|---|---|
| Head impulse test | Ask the patient to fix their gaze on your nose. Rapidly turn their head ~10–20° to one side, then back to centre. | Abnormal head impulse test: when the head is turned towards the affected side, the eyes briefly move away from the target, then make a visible corrective catch-up saccade back to the centre (fixating on the nose) | Normal head impulse test: eyes remain fixed on the nose during rapid heave movement (no corrective saccade) |
| Nystagmus | Look for nystagmus when the patient is looking straight, and looking towards the sides | Unidirectional, horizontal nystagmus regardless of gaze direction | Direction-changing nystagmus (direction of nystagmus changes depending on where the patient looks), or vertical nystagmus |
| Test of skew | Ask the patient to look at your nose. Cover one eye, then rapidly uncover it while observing for vertical correction. | Normal: when the eye is uncovered, the eye is already fixated on the nose (no vertical movement to re-fixate) | Abnormal: when the eye is uncovered, it moves upwards or downwards to refixate on the nose |