Vertigo results from the mismatch of the perception of movement by the visual, vestibular, and proprioceptive symptoms when none actually exists.
Vertigo is classically described as “the room is spinning,” but can also include atypical sensations of other types of movement. Vertigo is classified as peripheral or central (Table 144-1). Peripheral vertigo (involving vestibular apparatus and eighth cranial nerve) usually has a sudden onset and intense symptoms. Central vertigo (involving brainstem and cerebellum) can present abruptly or gradually, but usually has more ill-defined, less severe symptoms. Attempt to discriminate between the 2 in the ED, whilst recognizing significant overlap exists.
Table 144-1 Differentiating Peripheral from Central Vertigo |Favorite Table|Download (.pdf)
Table 144-1 Differentiating Peripheral from Central Vertigo
Sudden or slow
Severity of vertigo
Ill defined, less intense
Aggravated by position/movement
Fatigue of symptoms/signs
Does not occur
Abnormal tympanic membrane
Does not occur
Central nervous system symptoms/signs
The differential diagnosis for vertigo (Table 144-2) is extensive and certain key findings should be sought on history and physical examination. The initial episode should be described in detail by the patient including speed of onset, severity, associated symptoms (especially involving cranial nerves, loss of consciousness), and temporal pattern. Risk factors for stroke (age, hypertension, cardiovascular disease) and coagulopathy should be investigated. Physical examination should include eye (ie, nystagmus), ear, neurologic, and vestibular examinations, with particular focus on the cranial nerve and cerebellar examinations. If benign paroxysmal positional vertigo (BPPV) is suspected, a Dix-Hallpike position test may be useful (sensitivity 50% to 80%).
Table 144-2 an Etiologic Classification of Vertigo |Favorite Table|Download (.pdf)
Table 144-2 an Etiologic Classification of Vertigo
Benign paroxysmal positional vertigo
Traumatic: following head injury
Infection: labyrinthitis, vestibular neuronitis, Ramsay-Hunt syndrome
Toxic or drug-induced: aminoglycosides
Lateral Wallenberg syndrome
Anterior inferior cerebellar artery syndrome
Neoplastic: cerebellopontine angle tumors
Cerebellar disorders: hemorrhage, degeneration
Basal ganglion diseases
Infections: neurosyphilis, tuberculosis
Hematologic: anemia, polycythemia, hyperviscosity syndrome
Chronic renal failure
Metabolic: thyroid disease, hypoglycemia
In general, laboratory investigations are not indicated in vertiginous patients unless a specific cause for central vertigo is being investigated. With regards to imaging, the question of whether to obtain an emergent CT or MRI should be driven by the specific differential for a particular patient. However, an emergent noncontrast head CT should be obtained in elders, patients who have signs/symptoms of central vertigo (especially cranial nerve or cerebellar findings), hypertension, cardiovascular disease, other stroke risks, coagulopathy (eg, taking warfarin), headache, or intractable or persistent (>72 hours) symptoms. If vertebrobasilar insufficiency ...