What is Vertigo?

Vertigo is sensation of movement , either of the patient in relation to the their environment or environment in relation to the patient.

What is the difference between Vertigo and Dizziness?


Difficult to define, may result form conditions of the inner  ear or non ear conditions. Key – a good history to differentiate whether its vertigo or not.


The sense of feeling off  balance without any actual sensation of movement.


the feeling of light headedness, often without any sensation of movement and often accompanied by a sense of impending loss of consciousness.


  • Usually caused by the dysfunctio Symptom  rather  than  a disease.
  • Usually caused by the dysfunction of the middle ear.
  • Means  different things to different people.
  • Often has a rotational or spinning component.
  • Means  different things to different people.
  • Often has a rotational or spinning component.
  • Vertigo is not a general imbalance or a light headedness or faint like disorientation n of the middle ear.

Anatomy and physiology:

  • Inner ear is about 2cm long and has 2 main parts.
  • The cochlea and the vestibular system.
  • The vestibular system comprised of
  • 3 semicircular canals -3 diff planes
  • Otolith organs
  • The cochlea is concerned with hearing while the  vestibular system deals with balance.


  • Onset of the symptoms
  • Describe the symptoms
  • Tell me what it feels like ?
  • Avoid leading Q.
  • Patient might make a gesture using  the hand or the finger often a rotational movement ( This usually suggest U/L disease.)
  • Time course : Is it worsening resolving or fluctuating?

Associated Symptoms:

– Nausea

– Anxiety

– Neurological symptoms

Are the episodes spontaneous or provoked ( eg: Head movement).

H/O Ear Symptoms:

  • Earache, discharge, tinnitus, hearing loss
  • Neurological symptoms
  • Ophthalmological symptoms
  • Family history
  • Other RF for inner ear disease

– Head injury

– Whiplash injury

– Ototoxic medication

How to make sure that this is vertigo or something else?

– How sure  am I that this is only a peripheral  vestibular disorder?

– Should I seek ENT / Neuro/ Medical advise?

– Is this BPPV ?  Is Epley’s  manoeuvre indicated?

Examination of Vertigo

  • Balance.
  • Gait- pt with vestibular pathology may  turn sharply  towards the side of the lesion and use a wide based gait.
  • Otoscopy and tuning folk test for hearing.
  • Eyes- eye movements, nystagmus.
  • CNS examination- cerebellar signs, CN.

Start observing while patient walks into the room ( patient with a vestibular D, often stares at the floor to keep the balance especially in an unfamiliar setting).

Peripheral causes of  Vertigo:

  • Vestibular Neuronitis
  • BPPV
  • Meniere’s Disease
  • Recurrent vestibulopathy

Vestibular Neuronitis and Labrynthitis:

  • Cause unknown.
  • Could be due to  viral infection, therefore could have preceding URTI.
  • Typically pt present with features of vertigo which lasts for days to weeks.
  • Nystagmus  is usually present.
  • Acute labrynthitis is form of vestibular neuronitis, which involves a single attack of vertigo, with hearing loss and often tinnitus.
  • Hearing loss and tinnitus is often helpful to lateralise the lesion.

Note – sudden onset hearing loss is an emergency.

  • Rx   – Vestibular sedatives – prochloroperazine ,
  • Should not be prescribed more than a week

as prolonged vestibular sedation interrupts the process of recalibration process and hinder the recovery.


  • Self limiting , resolves spontaneously.
  • Episodes of vertigo with nausea and general imbalance,  lasting up to a minute.
  • Usually precipitated by certain head movements.
  • Often lasting no longer than few months.
  • Dix- Hallpike positional testing is diagnostic and  is treated with performing Epley’s manoeuvre.

Meniere’s Disease:

  • Triad of vertigo, hearing loss and tinnitus
  • Often describes an association of the feeling fullness in ear canal
  • Episodes lasts for 30minutes to several hours.
  • Difference with vestibular neuronitis
  • Vestibular neuronitis :  Single Attack
  • Meniere’s   : multiple  attacks

Meniere’s Disease:

  • all new cases need to be referred to ENT.
  • regulating salt and fluid intake, caffeine and smoking reduction  has shown some benefit.
  • Vestibular sedatives – prochloroperazine for acute phase.
  • Betahistine – for maintenance.

Recurrent Vestibulopathy:

  • Recurrent vertigo ,
  • Episodes which last from 5 minutes to 24 hours,
  • Occur in the absence of auditory or neurological symptom or signs.
  • The spells occur without a prodrome and with not provoked  particular movement.


Onset Duration Precipitants Associations
Vestibular neuronitis Sudden Constant for many hours / even a day Viral illness Nausea , vomiting
BPPV Intermittent Up to 60 seconds Head movements None
Meniere’s disease Intermittent Unpredictable , may  hours Tinnitus


Aural fullness

Recurrent vestibulopathy Intermittent Episodes last minutes to hours

Central vestibular Disorders:

  • CVA, brain tumours, MS.
  • Do not exhibit vertigo as their only presenting symptom.
  • Often present with associated  neurological deficits.
  • CN examination, fundoscopy , neuro examination mandatory.

Vestibular Migraine:

  • Migraine associated with dizziness.
  • Often incorrectly diagnosed as Meniere’s.
  • Presents with the classic symptoms of  Meniere’s.
  • Only difference is presence of other classic signs of migraine ( aura, photophobia and headache).

Can allergy cause Vertigo?

  • Yes, when associated with allergic rhinitis. when allergens enter the body through mouth and nose, then body tries to push it out with mucus.
  • Unfortunately body produces excess amount of mucus with some fluid. this build up of fluid and mucus in sinuses affects vestibular system.
  • The vestibular system and the eustachian tube are responsible of  sense of balance.
  • So if the eustachian tube is blocked then variety of symptoms develop  like these include  dizziness,  vertigo, nausea and   vomiting.

Key Points of Vertigo

  • Good  history.
  • 3 common peripheral vestibular disorders , distinguished from history by identifying the duration of the symptoms and associated symptoms.
  • R/O important central causes for vertigo.

Can We Use Meclizine For Vertigo?

  • Yes, in case  of patients having vertigo with allergic rhinitis we can use  meclizine or any other.
  • Anti histamine  I.E
  • Meclizine or
  • Cinnarizine


  • Anti histamines
  • I.E
  • Meclizine
  • Cinnarizine


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