Medicine – Causes of Vertigo

Vertigo is the false sensation that the patient or surroundings are moving, usually described as spinning, tilting, or rotating. It results from dysfunction of the vestibular system and is broadly divided into peripheral vertigo, arising from the inner ear or vestibular nerve, and central vertigo, arising from the brainstem or cerebellar pathways.

A useful first step is:

Peripheral vertigo → inner ear/vestibular apparatus.

Central vertigo → brainstem or cerebellum.

1. Peripheral Vertigo

Peripheral vertigo results from disease affecting the labyrinth, semicircular canals, vestibular apparatus, or vestibular nerve.

It is often associated with:

Severe spinning sensation.

Nausea and vomiting.

Positional worsening.

Horizontal or rotatory nystagmus.

Depending on the cause, hearing loss or tinnitus may also occur.

2. Viral Vestibular Disease

A common peripheral cause is viral vestibular neuritis.

This typically presents with:

Acute severe vertigo.

Nausea and vomiting.

Unsteadiness.

No major hearing loss.

Symptoms may persist for hours to days.

The disorder is thought to involve inflammation of the vestibular nerve, often following or associated with a viral illness.

3. Labyrinthitis

If acute vertigo occurs together with hearing loss, the diagnosis may be labyrinthitis rather than isolated vestibular neuritis.

This distinction is useful:

Vestibular neuritis → vertigo without significant hearing loss.

Labyrinthitis → vertigo + hearing impairment.

4. Ménière Disease

Ménière disease is an important peripheral cause of recurrent vertigo.

The classical pattern is:

Episodic vertigo.

Fluctuating sensorineural hearing loss.

Tinnitus.

Aural fullness or pressure.

The condition is associated with abnormal regulation of endolymph within the inner ear.

5. Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of peripheral vertigo.

It produces brief episodes of vertigo triggered by changes in head position, such as:

Turning over in bed.

Looking upward.

Getting out of bed.

Bending down.

Episodes usually last seconds rather than hours.

6. Mechanism of BPPV

BPPV is usually caused by displaced otoconia entering a semicircular canal, most commonly the posterior canal.

Head movement causes abnormal movement of these particles, stimulating the vestibular system and producing vertigo.

Therefore:

Displaced otoconia → abnormal semicircular canal stimulation → positional vertigo.

7. Chronic Otitis Media

Chronic middle-ear disease can occasionally cause vertigo, particularly when infection or inflammation extends toward the labyrinth or produces complications.

Therefore, chronic otitis media can be associated with peripheral vertigo, but uncomplicated otitis media itself is not among the most typical causes of isolated vertigo.

8. Internal Auditory Artery Occlusion

Occlusion of the internal auditory artery, also called the labyrinthine artery, can cause sudden vestibular dysfunction.

Patients may develop:

Sudden severe vertigo.

Sudden sensorineural hearing loss.

This is important because vascular inner-ear disease can resemble other peripheral vestibular disorders.

9. Central Vertigo

Central vertigo results from disease affecting the brainstem, cerebellum, or central vestibular pathways.

It is especially important because some causes are potentially life-threatening.

Central vertigo may be associated with other neurological abnormalities such as:

Diplopia.

Dysarthria.

Limb weakness.

Sensory loss.

Severe ataxia.

Cranial nerve abnormalities.

10. Stroke

Stroke is one of the most important central causes of acute vertigo.

Posterior-circulation ischaemia involving the:

Brainstem.

Cerebellum.

can present with vertigo and imbalance.

A stroke should be considered particularly when vertigo is associated with new focal neurological findings or severe inability to stand or walk.

11. Posterior Circulation Stroke

Cerebellar or brainstem infarction may produce:

Sudden vertigo.

Nystagmus.

Vomiting.

Severe gait or truncal ataxia.

Additional symptoms may include:

Diplopia.

Dysarthria.

Dysphagia.

Weakness or sensory disturbance.

The absence of obvious limb weakness does not completely exclude a posterior-circulation stroke.

12. Alcohol

Acute alcohol intoxication can disturb cerebellar and vestibular function.

This may cause:

Dizziness or vertigo.

Nystagmus.

Ataxia.

Poor coordination.

Therefore, alcohol is an important toxic/metabolic contributor to central vestibular symptoms.

13. Drugs

Several medications can produce dizziness, vertigo, ataxia, or vestibular toxicity.

Examples include some:

Anticonvulsants.

Sedatives.

Aminoglycoside antibiotics.

Certain chemotherapy agents.

A careful medication history is therefore important in a patient presenting with vertigo.

14. Multiple Sclerosis

Multiple sclerosis can produce central vertigo when demyelinating plaques involve the brainstem or cerebellar vestibular pathways.

Other features suggesting MS may include:

Optic neuritis.

Diplopia.

Internuclear ophthalmoplegia.

Sensory symptoms.

Upper motor neurone signs.

Ataxia.

15. Space-Occupying Lesion

A space-occupying lesion, such as a tumour affecting the brainstem or cerebellum, can produce vertigo.

Examples include:

Glioma.

Cerebellar tumour.

Posterior-fossa mass.

Symptoms may be gradual and progressive rather than suddenly episodic.

16. Migraine

Vestibular migraine is an important and relatively common cause of recurrent vertigo.

Vertigo may occur:

With headache.

Before headache.

Without headache during some attacks.

Patients may also have typical migraine features such as photophobia, phonophobia, visual aura, or a previous migraine history.

17. Hypoglycaemia

Hypoglycaemia can cause dizziness, weakness, confusion, and unsteadiness.

True rotational vertigo is less specific, but hypoglycaemia should be considered in an acutely unwell patient with neurological or autonomic symptoms.

Associated features may include:

Sweating.

Tremor.

Palpitations.

Confusion.

Reduced consciousness.

18. Peripheral Vertigo – Note Form

BPPV: brief positional attacks, typically seconds, triggered by head movement.

Vestibular neuritis: acute prolonged vertigo, usually without hearing loss.

Labyrinthitis: vertigo with hearing impairment.

Ménière disease: episodic vertigo + fluctuating hearing loss + tinnitus + aural fullness.

Chronic otitis media: may cause vertigo when complicated by inner-ear involvement.

Internal auditory/labyrinthine artery occlusion: sudden vertigo often with sudden hearing loss.

19. Central Vertigo – Note Form

Stroke: sudden vertigo with possible brainstem or cerebellar neurological signs.

Alcohol: intoxication may cause vertigo, nystagmus and ataxia.

Drugs: sedative, anticonvulsant or vestibulotoxic medications can cause symptoms.

Multiple sclerosis: demyelinating brainstem or cerebellar lesions.

Space-occupying lesion: brainstem or cerebellar tumour, such as glioma.

Migraine: vestibular migraine causes recurrent vertigo, sometimes without headache.

Hypoglycaemia: metabolic cause of dizziness/unsteadiness and occasionally vertigo-like symptoms.

20. Peripheral versus Central Vertigo – Quick Note Form

Peripheral vertigo: usually more intense spinning and nausea.

Central vertigo: may be less intensely spinning but is more likely to have neurological signs.

Peripheral hearing symptoms: may occur, especially Ménière disease, labyrinthitis, or labyrinthine artery occlusion.

Central hearing symptoms: generally less typical, depending on lesion location.

Peripheral neurological deficits: usually absent.

Central neurological deficits: may include diplopia, dysarthria, weakness, sensory loss or marked ataxia.

Peripheral causes: BPPV, vestibular neuritis, labyrinthitis, Ménière disease.

Central causes: stroke, MS, migraine, tumours, drugs or toxins.

Key Clinical Pattern

The easiest way to remember the common causes is:

Peripheral vertigo → BPPV + vestibular neuritis/labyrinthitis + Ménière disease.

Central vertigo → stroke + MS + vestibular migraine + posterior-fossa lesions.

A very useful clinical clue is:

Vertigo + hearing symptoms → think peripheral inner-ear disease.

Vertigo + focal neurological signs or severe central ataxia → think central cause, especially posterior-circulation stroke.