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Pathophysiology, etiology, and differential diagnosis of vertigo

Joseph M Furman, MD, PhD
Section Editors
Michael J Aminoff, MD, DSc
Daniel G Deschler, MD, FACS
Deputy Editor
Janet L Wilterdink, MD


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 only one type of dizziness. Other disorders that present with 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. (See "Approach to the patient with dizziness".)

The pathophysiology, etiology, and differential diagnosis of vertigo will be reviewed here. The clinical approach, diagnosis, and treatment of vertigo are discussed separately. (See "Evaluation of the patient with vertigo" and "Treatment of vertigo".)


The end organs of the vestibular system, the semicircular canals and the otolith organs, sense angular and linear motion, respectively. As a result, a patient's description of a spinning sensation is likely to indicate an abnormality of the semicircular canals or the central nervous system structures that process signals from the semicircular canals. Similarly, an illusory sensation of floating or tilting may indicate an otolith system disorder.

Important to the pathogenesis of vertigo is the fact that there is a vestibular labyrinth on each side of the body. The central nervous system receives signals from both the right and left labyrinths and compares these signals with one another. When the head is still, tonic discharges in both vestibular afferents are exactly balanced. During motion, the right and left labyrinths are alternately excited and inhibited, leading to a left-right difference in eighth nerve activity, which is recognized as motion. The spurious left-right differences that result from an acute unilateral peripheral vestibular disorder are also interpreted by the central nervous system as motion or vertigo.


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Literature review current through: Sep 2016. | This topic last updated: Jun 3, 2015.
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  1. Mazzola L, Lopez C, Faillenot I, et al. Vestibular responses to direct stimulation of the human insular cortex. Ann Neurol 2014; 76:609.
  2. Kroenke K, Hoffman RM, Einstadter D. How common are various causes of dizziness? A critical review. South Med J 2000; 93:160.
  3. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999; 341:1590.
  4. Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med 2014; 370:1138.
  5. Watson P, Barber HO, Deck J, Terbrugge K. Positional vertigo and nystagmus of central origin. Can J Neurol Sci 1981; 8:133.
  6. Dunniway HM, Welling DB. Intracranial tumors mimicking benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1998; 118:429.
  7. Baloh RW. Clinical practice. Vestibular neuritis. N Engl J Med 2003; 348:1027.
  8. Hotson JR, Baloh RW. Acute vestibular syndrome. N Engl J Med 1998; 339:680.
  9. Norrving B, Magnusson M, Holtås S. Isolated acute vertigo in the elderly; vestibular or vascular disease? Acta Neurol Scand 1995; 91:43.
  10. Sweeney CJ, Gilden DH. Ramsay Hunt syndrome. J Neurol Neurosurg Psychiatry 2001; 71:149.
  11. Friedman JM. Post-traumatic vertigo. Med Health R I 2004; 87:296.
  12. Hoffer ME, Gottshall KR, Moore R, et al. Characterizing and treating dizziness after mild head trauma. Otol Neurotol 2004; 25:135.
  13. Gordon CR, Levite R, Joffe V, Gadoth N. Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form? Arch Neurol 2004; 61:1590.
  14. Ernst A, Basta D, Seidl RO, et al. Management of posttraumatic vertigo. Otolaryngol Head Neck Surg 2005; 132:554.
  15. Seltzer S, McCabe BF. Perilymph fistula: the Iowa experience. Laryngoscope 1986; 96:37.
  16. Casselman JW. Diagnostic imaging in clinical neuro-otology. Curr Opin Neurol 2002; 15:23.
  17. Kozuka M, Nakashima T, Fukuta S, Yanagita N. Inner ear disorders due to pressure change. Clin Otolaryngol Allied Sci 1997; 22:106.
  18. Maitland CG. Perilymphatic fistula. Curr Neurol Neurosci Rep 2001; 1:486.
  19. Baloh RW. Superior semicircular canal dehiscence syndrome: Leaks and squeaks can make you dizzy. Neurology 2004; 62:684.
  20. Minor LB. Superior canal dehiscence syndrome. Am J Otol 2000; 21:9.
  21. Minor LB, Cremer PD, Carey JP, et al. Symptoms and signs in superior canal dehiscence syndrome. Ann N Y Acad Sci 2001; 942:259.
  22. Welgampola MS, Myrie OA, Minor LB, Carey JP. Vestibular-evoked myogenic potential thresholds normalize on plugging superior canal dehiscence. Neurology 2008; 70:464.
  23. Watson SR, Halmagyi GM, Colebatch JG. Vestibular hypersensitivity to sound (Tullio phenomenon): structural and functional assessment. Neurology 2000; 54:722.
  24. Hirvonen TP, Carey JP, Liang CJ, Minor LB. Superior canal dehiscence: mechanisms of pressure sensitivity in a chinchilla model. Arch Otolaryngol Head Neck Surg 2001; 127:1331.
  25. Aw ST, Todd MJ, Aw GE, et al. Click-evoked vestibulo-ocular reflex: stimulus-response properties in superior canal dehiscence. Neurology 2006; 66:1079.
  26. Rosengren SM, Aw ST, Halmagyi GM, et al. Ocular vestibular evoked myogenic potentials in superior canal dehiscence. J Neurol Neurosurg Psychiatry 2008; 79:559.
  27. Niesten ME, McKenna MJ, Herrmann BS, et al. Utility of cVEMPs in bilateral superior canal dehiscence syndrome. Laryngoscope 2013; 123:226.
  28. Minor LB, Carey JP, Cremer PD, et al. Dehiscence of bone overlying the superior canal as a cause of apparent conductive hearing loss. Otol Neurotol 2003; 24:270.
  29. Halmagyi GM, Aw ST, McGarvie LA, et al. Superior semicircular canal dehiscence simulating otosclerosis. J Laryngol Otol 2003; 117:553.
  30. Lempert T, von Brevern M. Episodic vertigo. Curr Opin Neurol 2005; 18:5.
  31. Hain TC, Cherchi M. Pulse-synchronous torsional pendular nystagmus in unilateral superior canal dehiscence. Neurology 2008; 70:1217.
  32. Belden CJ, Weg N, Minor LB, Zinreich SJ. CT evaluation of bone dehiscence of the superior semicircular canal as a cause of sound- and/or pressure-induced vertigo. Radiology 2003; 226:337.
  33. Elmali M, Polat AV, Kucuk H, et al. Semicircular canal dehiscence: frequency and distribution on temporal bone CT and its relationship with the clinical outcomes. Eur J Radiol 2013; 82:e606.
  34. Hüfner K, Barresi D, Glaser M, et al. Vestibular paroxysmia: diagnostic features and medical treatment. Neurology 2008; 71:1006.
  35. Best C, Gawehn J, Krämer HH, et al. MRI and neurophysiology in vestibular paroxysmia: contradiction and correlation. J Neurol Neurosurg Psychiatry 2013; 84:1349.
  36. De Carpentier J, Lynch N, Fisher A, et al. MR imaged neurovascular relationships at the cerebellopontine angle. Clin Otolaryngol Allied Sci 1996; 21:312.
  37. Strupp M, von Stuckrad-Barre S, Brandt T, Tonn JC. Teaching neuroimages: Compression of the eighth cranial nerve causes vestibular paroxysmia. Neurology 2013; 80:e77.
  38. Rutka JA, Barber HO. Recurrent vestibulopathy: third review. J Otolaryngol 1986; 15:105.
  39. Oh AK, Lee H, Jen JC, et al. Familial benign recurrent vertigo. Am J Med Genet 2001; 100:287.
  40. WERSALL J, HAWKINS JE Jr. The vestibular sensory epithelia in the cat labyrinth and their reactions in chronic streptomycin intoxication. Acta Otolaryngol 1962; 54:1.
  41. Minor LB. Gentamicin-induced bilateral vestibular hypofunction. JAMA 1998; 279:541.
  42. Weber KP, Aw ST, Todd MJ, et al. Horizontal head impulse test detects gentamicin vestibulotoxicity. Neurology 2009; 72:1417.
  43. Zingler VC, Weintz E, Jahn K, et al. Follow-up of vestibular function in bilateral vestibulopathy. J Neurol Neurosurg Psychiatry 2008; 79:284.
  44. Meyerhoff WL, Kim CS, Paparella MM. Pathology of chronic otitis media. Ann Otol Rhinol Laryngol 1978; 87:749.
  45. Minor LB. Labyrinthine fistulae: pathobiology and management. Curr Opin Otolaryngol Head Neck Surg 2003; 11:340.
  46. Dieterich M, Brandt T. Why acute unilateral vestibular cortex lesions mostly manifest without vertigo. Neurology 2015; 84:1680.
  47. von Brevern M, Zeise D, Neuhauser H, et al. Acute migrainous vertigo: clinical and oculographic findings. Brain 2005; 128:365.
  48. Furman JM, Marcus DA, Balaban CD. Migrainous vertigo: development of a pathogenetic model and structured diagnostic interview. Curr Opin Neurol 2003; 16:5.
  49. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 2013; 33:629.
  50. Abu-Arafeh I, Russell G. Paroxysmal vertigo as a migraine equivalent in children: a population-based study. Cephalalgia 1995; 15:22.
  51. 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.
  52. Baloh RW. Vertebrobasilar insufficiency and stroke. Otolaryngol Head Neck Surg 1995; 112:114.
  53. Ho CY, Douglas-Akinwande AC, Rankin JL. Multichannel computed tomography angiography and its role in the evaluation of rotational vertebrobasilar insufficiency. J Comput Assist Tomogr 2008; 32:151.
  54. Dabus G, Gerstle RJ, Parsons M, et al. Rotational vertebrobasilar insufficiency due to dynamic compression of the dominant vertebral artery by the thyroid cartilage and occlusion of the contralateral vertebral artery at C1-2 level. J Neuroimaging 2008; 18:184.
  55. Bulsara KR, Velez DA, Villavicencio A. Rotational vertebral artery insufficiency resulting from cervical spondylosis: case report and review of the literature. Surg Neurol 2006; 65:625.
  56. Miele VJ, France JC, Rosen CL. Subaxial positional vertebral artery occlusion corrected by decompression and fusion. Spine (Phila Pa 1976) 2008; 33:E366.
  57. Petridis AK, Barth H, Buhl R, Mehdorn HM. Vertebral artery decompression in a patient with rotational occlusion. Acta Neurochir (Wien) 2008; 150:391.
  58. D'Angelo VA, Galarza M, Catapano D, et al. Lateral ventricle tumors: surgical strategies according to tumor origin and development--a series of 72 cases. Neurosurgery 2005; 56:36.
  59. Choi KD, Choi JH, Kim JS, et al. Rotational vertebral artery occlusion: mechanisms and long-term outcome. Stroke 2013; 44:1817.
  60. FISHER CM, KARNES WE, KUBIK CS. Lateral medullary infarction-the pattern of vascular occlusion. J Neuropathol Exp Neurol 1961; 20:323.
  61. Kim JS. Vertigo and gait ataxia without usual signs of lateral medullary infarction: a clinical variant related to rostral-dorsolateral lesions. Cerebrovasc Dis 2000; 10:471.
  62. Kim HA, Lee H. Isolated vestibular nucleus infarction mimicking acute peripheral vestibulopathy. Stroke 2010; 41:1558.
  63. Schwartz NE, Venkat C, Albers GW. Transient isolated vertigo secondary to an acute stroke of the cerebellar nodulus. Arch Neurol 2007; 64:897.
  64. Tarnutzer AA, Lee SH, Robinson KA, et al. Clinical and electrographic findings in epileptic vertigo and dizziness: a systematic review. Neurology 2015; 84:1595.
  65. Solomon D. Distinguishing and treating causes of central vertigo. Otolaryngol Clin North Am 2000; 33:579.
  66. Fernández AA, Guerrero AI, Martínez MI, et al. Malformations of the craniocervical junction (Chiari type I and syringomyelia: classification, diagnosis and treatment). BMC Musculoskelet Disord 2009; 10 Suppl 1:S1.
  67. Klekamp J, Batzdorf U, Samii M, Bothe HW. The surgical treatment of Chiari I malformation. Acta Neurochir (Wien) 1996; 138:788.
  68. Dones J, De Jesús O, Colen CB, et al. Clinical outcomes in patients with Chiari I malformation: a review of 27 cases. Surg Neurol 2003; 60:142.
  69. Frohman EM, Kramer PD, Dewey RB, et al. Benign paroxysmal positioning vertigo in multiple sclerosis: diagnosis, pathophysiology and therapeutic techniques. Mult Scler 2003; 9:250.
  70. Anagnostou E, Mandellos D, Limbitaki G, et al. Positional nystagmus and vertigo due to a solitary brachium conjunctivum plaque. J Neurol Neurosurg Psychiatry 2006; 77:790.
  71. Frohman EM, Zhang H, Dewey RB, et al. Vertigo in MS: utility of positional and particle repositioning maneuvers. Neurology 2000; 55:1566.
  72. Ophoff RA, Terwindt GM, Vergouwe MN, et al. Familial hemiplegic migraine and episodic ataxia type-2 are caused by mutations in the Ca2+ channel gene CACNL1A4. Cell 1996; 87:543.
  73. Vighetto A, Froment JC, Trillet M, Aimard G. Magnetic resonance imaging in familial paroxysmal ataxia. Arch Neurol 1988; 45:547.
  74. Baloh RW, Yue Q, Furman JM, Nelson SF. Familial episodic ataxia: clinical heterogeneity in four families linked to chromosome 19p. Ann Neurol 1997; 41:8.
  75. Cha YH. Mal de debarquement. Semin Neurol 2009; 29:520.
  76. Cha YH, Brodsky J, Ishiyama G, et al. Clinical features and associated syndromes of mal de debarquement. J Neurol 2008; 255:1038.
  77. DeFlorio PT, Silbergleit R. Mal de debarquement presenting in the Emergency Department. J Emerg Med 2006; 31:377.
  78. Gordon CR, Spitzer O, Doweck I, et al. Clinical features of mal de debarquement: adaptation and habituation to sea conditions. J Vestib Res 1995; 5:363.
  79. Hain TC, Hanna PA, Rheinberger MA. Mal de debarquement. Arch Otolaryngol Head Neck Surg 1999; 125:615.
  80. Nachum Z, Shupak A, Letichevsky V, et al. Mal de debarquement and posture: reduced reliance on vestibular and visual cues. Laryngoscope 2004; 114:581.