Evaluation of the patient with vertigo
- Joseph M Furman, MD, PhD
Joseph M Furman, MD, PhD
- University of Pittsburgh
- Jason JS Barton, MD, PhD, FRCPC
Jason JS Barton, MD, PhD, FRCPC
- Professor and Canada Research Chair
- Medicine (Neurology), Ophthalmology, and Visual Sciences
- The University of British Columbia
- Section Editors
- Michael J Aminoff, MD, DSc
Michael J Aminoff, MD, DSc
- Editor-in-Chief — Neurology
- Section Editor — Medical Neurology
- Professor of Neurology
- University of California, San Francisco School of Medicine
- Robert S Hockberger, MD, FACEP
Robert S Hockberger, MD, FACEP
- Section Editor — Adult Signs and Symptoms
- Emeritus Professor of Medicine
- David Geffen School of Medicine at UCLA
- Daniel G Deschler, MD, FACS
Daniel G Deschler, MD, FACS
- Section Editor — Otorhinolaryngology
- Professor of Otology and Laryngology
- Harvard Medical School
Vertigo is a symptom of illusory movement. Almost everyone has experienced vertigo as the transient spinning dizziness immediately after turning around rapidly several times. Vertigo can also be a sense of swaying or tilting. Some perceive self-motion whereas others perceive motion of the environment.
Vertigo is a symptom, not a diagnosis. It arises because of asymmetry in the vestibular system due to damage to or dysfunction of the labyrinth, vestibular nerve, or central vestibular structures in the brainstem.
Vertigo is a troubling problem for many clinicians because it is symptomatic of a large range of diagnoses from benign to immediately life threatening (table 1). However, in most cases, the clinical history, especially the tempo of the symptoms (table 2), with examination findings that distinguish between central and peripheral etiologies (table 3) identify those patients that require urgent diagnostic evaluation.
Vertigo is only one type of dizziness. Other symptoms that patients may identify as dizziness include presyncopal faintness, disequilibrium, and nonspecific or ill-defined light-headedness. The initial approach to the patient who complains of dizziness is to localize the cause of the symptom into one of these broad categories. This is described separately. (See "Approach to the patient with dizziness".)
This topic will discuss the clinical approach to a patient with vertigo. The pathophysiology, etiology, and treatment of vertigo are discussed separately. (See "Pathophysiology, etiology, and differential diagnosis of vertigo" and "Treatment of vertigo".)
- Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006; 37:2484.
- Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg 1998; 119:55.
- Lee H, Yi HA, Lee SR, et al. Drop attacks in elderly patients secondary to otologic causes with Meniere's syndrome or non-Meniere peripheral vestibulopathy. J Neurol Sci 2005; 232:71.
- Ishiyama G, Ishiyama A, Jacobson K, Baloh RW. Drop attacks in older patients secondary to an otologic cause. Neurology 2001; 57:1103.
- Dallan I, Bruschini L, Nacci A, et al. Drop attacks and vertical vertigo after transtympanic gentamicin: diagnosis and management. Acta Otorhinolaryngol Ital 2005; 25:370.
- Brantberg K, Ishiyama A, Baloh RW. Drop attacks secondary to superior canal dehiscence syndrome. Neurology 2005; 64:2126.
- Lehnen N, Glasauer S, Jahn K, Weber KP. Head impulses in complete bilateral vestibular loss: catch-up saccades require visual input. Neurology 2013; 81:688.
- Zingler VC, Cnyrim C, Jahn K, et al. Causative factors and epidemiology of bilateral vestibulopathy in 255 patients. Ann Neurol 2007; 61:524.
- Szmulewicz DJ, McLean CA, MacDougall HG, et al. CANVAS an update: clinical presentation, investigation and management. J Vestib Res 2014; 24:465.
- Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999; 341:1590.
- Baloh RW. Vertebrobasilar insufficiency and stroke. Otolaryngol Head Neck Surg 1995; 112:114.
- Saeed SR. Fortnightly review. Diagnosis and treatment of Ménière's disease. BMJ 1998; 316:368.
- Knox GW, McPherson A. Menière's disease: differential diagnosis and treatment. Am Fam Physician 1997; 55:1185.
- Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med 1998; 339:680.
- Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med 2003; 348:1027.
- Stanton VA, Hsieh YH, Camargo CA Jr, et al. Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians. Mayo Clin Proc 2007; 82:1319.
- Minor LB. Superior canal dehiscence syndrome. Am J Otol 2000; 21:9.
- Watson SR, Halmagyi GM, Colebatch JG. Vestibular hypersensitivity to sound (Tullio phenomenon): structural and functional assessment. Neurology 2000; 54:722.
- Marzo SJ, Leonetti JP, Raffin MJ, Letarte P. Diagnosis and management of post-traumatic vertigo. Laryngoscope 2004; 114:1720.
- DIX MR, HALLPIKE CS. The pathology symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med 1952; 45:341.
- Silvoniemi P. Vestibular neuronitis. An otoneurological evaluation. Acta Otolaryngol Suppl 1988; 453:1.
- Yardley L. Overview of psychologic effects of chronic dizziness and balance disorders. Otolaryngol Clin North Am 2000; 33:603.
- Lee CC, Su YC, Ho HC, et al. Risk of stroke in patients hospitalized for isolated vertigo: a four-year follow-up study. Stroke 2011; 42:48.
- Gold DR, Reich SG. Clinical reasoning: a 55-year-old woman with vertigo. A dizzying conundrum. Neurology 2012; 79:e146.
- Newman-Toker DE, Sharma P, Chowdhury M, et al. Penlight-cover test: a new bedside method to unmask nystagmus. J Neurol Neurosurg Psychiatry 2009; 80:900.
- Traccis S, Zoroddu GF, Zecca MT, et al. Evaluating patients with vertigo: bedside examination. Neurol Sci 2004; 25 Suppl 1:S16.
- Cohen HS, Mulavara AP, Peters BT, et al. Standing balance tests for screening people with vestibular impairments. Laryngoscope 2014; 124:545.
- Hoffman RM, Einstadter D, Kroenke K. Evaluating dizziness. Am J Med 1999; 107:468.
- Halmagyi GM, Cremer PD. Assessment and treatment of dizziness. J Neurol Neurosurg Psychiatry 2000; 68:129.
- MacDougall HG, Weber KP, McGarvie LA, et al. The video head impulse test: diagnostic accuracy in peripheral vestibulopathy. Neurology 2009; 73:1134.
- Harvey SA, Wood DJ, Feroah TR. Relationship of the head impulse test and head-shake nystagmus in reference to caloric testing. Am J Otol 1997; 18:207.
- Harvey SA, Wood DJ. The oculocephalic response in the evaluation of the dizzy patient. Laryngoscope 1996; 106:6.
- Beynon GJ, Jani P, Baguley DM. A clinical evaluation of head impulse testing. Clin Otolaryngol Allied Sci 1998; 23:117.
- Jorns-Häderli M, Straumann D, Palla A. Accuracy of the bedside head impulse test in detecting vestibular hypofunction. J Neurol Neurosurg Psychiatry 2007; 78:1113.
- Schubert MC, Tusa RJ, Grine LE, Herdman SJ. Optimizing the sensitivity of the head thrust test for identifying vestibular hypofunction. Phys Ther 2004; 84:151.
- Weber KP, Aw ST, Todd MJ, et al. Horizontal head impulse test detects gentamicin vestibulotoxicity. Neurology 2009; 72:1417.
- Newman-Toker DE, Kattah JC, Alvernia JE, Wang DZ. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology 2008; 70:2378.
- Kattah JC, Talkad AV, Wang DZ, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009; 40:3504.
- Chen L, Lee W, Chambers BR, Dewey HM. Diagnostic accuracy of acute vestibular syndrome at the bedside in a stroke unit. J Neurol 2011; 258:855.
- Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 2013; 20:986.
- Newman-Toker DE, Saber Tehrani AS, Mantokoudis G, et al. Quantitative video-oculography to help diagnose stroke in acute vertigo and dizziness: toward an ECG for the eyes. Stroke 2013; 44:1158.
- Cohn B. Can bedside oculomotor (HINTS) testing differentiate central from peripheral causes of vertigo? Ann Emerg Med 2014; 64:265.
- Dieterich M, Brandt T. Ocular torsion and tilt of subjective visual vertical are sensitive brainstem signs. Ann Neurol 1993; 33:292.
- Zwergal A, Rettinger N, Frenzel C, et al. A bucket of static vestibular function. Neurology 2009; 72:1689.
- Lee H, Lee SY, Lee SR, et al. Ocular tilt reaction and anterior inferior cerebellar artery syndrome. J Neurol Neurosurg Psychiatry 2005; 76:1742.
- Baier B, Dieterich M. Ocular tilt reaction: a clinical sign of cerebellar infarctions? Neurology 2009; 72:572.
- Finke C, Ploner CJ. Pearls & Oy-sters: Vestibular neuritis or not?: The significance of head tilt in a patient with rotatory vertigo. Neurology 2009; 72:e101.
- Yang TH, Oh SY, Kwak K, et al. Topology of brainstem lesions associated with subjective visual vertical tilt. Neurology 2014; 82:1968.
- Baier B, Bense S, Dieterich M. Are signs of ocular tilt reaction in patients with cerebellar lesions mediated by the dentate nucleus? Brain 2008; 131:1445.
- Tusa RJ. Bedside assessment of the dizzy patient. Neurol Clin 2005; 23:655.
- Dros J, Maarsingh OR, van der Horst HE, et al. Tests used to evaluate dizziness in primary care. CMAJ 2010; 182:E621.
- Kim HA, Hong JH, Lee H, et al. Otolith dysfunction in vestibular neuritis: recovery pattern and a predictor of symptom recovery. Neurology 2008; 70:449.
- Mandalà M, Nuti D, Broman AT, Zee DS. Effectiveness of careful bedside examination in assessment, diagnosis, and prognosis of vestibular neuritis. Arch Otolaryngol Head Neck Surg 2008; 134:164.
- Choi KD, Oh SY, Park SH, et al. Head-shaking nystagmus in lateral medullary infarction: patterns and possible mechanisms. Neurology 2007; 68:1337.
- Choi KD, Kim JS, Kim HJ, et al. Hyperventilation-induced nystagmus in peripheral vestibulopathy and cerebellopontine angle tumor. Neurology 2007; 69:1050.
- Ahsan SF, Syamal MN, Yaremchuk K, et al. The costs and utility of imaging in evaluating dizzy patients in the emergency room. Laryngoscope 2013; 123:2250.
- Schwartz NE, Venkat C, Albers GW. Transient isolated vertigo secondary to an acute stroke of the cerebellar nodulus. Arch Neurol 2007; 64:897.
- Becker KJ, Purcell LL, Hacke W, Hanley DF. Vertebrobasilar thrombosis: diagnosis, management, and the use of intra-arterial thrombolytics. Crit Care Med 1996; 24:1729.
- Lawhn-Heath C, Buckle C, Christoforidis G, Straus C. Utility of head CT in the evaluation of vertigo/dizziness in the emergency department. Emerg Radiol 2013; 20:45.
- Herr RD, Alvord L, Johnson L, et al. Immediate electronystagmography in the diagnosis of the dizzy patient. Ann Emerg Med 1993; 22:1182.
- Young YH. Potential application of ocular and cervical vestibular-evoked myogenic potentials in Meniere's disease: a review. Laryngoscope 2013; 123:484.
- Iwasaki S, Smulders YE, Burgess AM, et al. Ocular vestibular evoked myogenic potentials in response to bone-conducted vibration of the midline forehead at Fz. A new indicator of unilateral otolithic loss. Audiol Neurootol 2008; 13:396.
- Minor LB. Clinical manifestations of superior semicircular canal dehiscence. Laryngoscope 2005; 115:1717.
- Johnson EW. Auditory findings in 200 cases of acoustic neuromas. Arch Otolaryngol 1968; 88:598.
- Harner SG, Laws ER Jr. Clinical findings in patients with acoustic neurinoma. Mayo Clin Proc 1983; 58:721.
- Selters WA, Brackmann DE. Acoustic tumor detection with brain stem electric response audiometry. Arch Otolaryngol 1977; 103:181.
- Bauch CD, Rose DE, Harner SG. Auditory brain stem response results from 255 patients with suspected retrocochlear involvement. Ear Hear 1982; 3:83.
- Chase M, Goldstein JN, Selim MH, et al. A prospective pilot study of predictors of acute stroke in emergency department patients with dizziness. Mayo Clin Proc 2014; 89:173.
- CLINICAL FEATURES
- Nausea and vomiting
- Postural and gait instability
- Other symptoms of vestibular dysfunction
- - Tilt illusion
- - Drop attacks
- - Spatial disorientation
- - Oscillopsia
- - Impaired balance without vertigo
- - Time course
- - Aggravating and provoking factors
- - Associated symptoms
- - Prior medical history
- - Nystagmus
- - Balance and gait
- - Other neurologic signs
- - Office hearing tests
- - Dix-Hallpike maneuver
- - Head impulse test
- - Other vestibular signs
- Diagnostic tests
- - Brain imaging
- - Electronystagmography and video nystagmography
- - Vestibular evoked myogenic potentials
- - Audiometry
- - Brainstem auditory evoked potentials
- DIAGNOSTIC APPROACH
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS