Signs and Symptoms: Peripheral

Vertigo is classified into either peripheral or central depending on the location of the dysfunction
of the vestibular pathway,[15] although it can also be caused by psychological factors.[16]
Peripheral
Vertigo caused by problems with the inner ear or vestibular system, which is composed of the
semicircular canals, the vestibule (utricle and saccule), and the vestibular nerve is called
"peripheral", "otologic" or "vestibular" vertigo.[5][17] The most common cause is benign
paroxysmal positional vertigo (BPPV), which accounts for 32% of all peripheral vertigo.[17]
Other causes include Mnire's disease (12%), superior canal dehiscence syndrome, labyrinthitis,
and visual vertigo.[17][18] Any cause of inflammation such as common cold, influenza, and
bacterial infections may cause transient vertigo if it involves the inner ear, as may chemical
insults (e.g., aminoglycosides)[19] or physical trauma (e.g., skull fractures). Motion sickness is
sometimes classified as a cause of peripheral vertigo.
Patients with peripheral vertigo typically present with mild to moderate imbalance, nausea,
vomiting, hearing loss, tinnitus, fullness, and pain in the ear.[17] In addition, lesions of the
internal auditory canal may be associated with facial weakness on the same side.[17] Due to a
rapid compensation process, acute vertigo as a result of a peripheral lesion tends to improve in a
short period of time (days to weeks).[17]
Central
Vertigo that arises from injury to the balance centers of the central nervous system (CNS), often
from a lesion in the brainstem or cerebellum,[5][8][20] is called "central" vertigo and is generally
associated with less prominent movement illusion and nausea than vertigo of peripheral
origin.[21] Central vertigo has accompanying neurologic deficits (such as slurred speech and
double vision), and pathologic nystagmus (which is pure vertical/torsional).[17][21] Central
pathology can cause disequilibrium which is the sensation of being off balance. The balance
disorder associated with central lesions causing vertigo is often so severe that many patients are
unable to stand or walk.[17]
A number of conditions that involve the central nervous system may lead to vertigo including:
lesions caused by infarctions or hemorrhage, tumors present in the cerebellopontine angle such
as a vestibular schwannoma or cerebellar tumors,[8][15] epilepsy,[2] cervical spine disorders such
as cervical spondylosis,[15] degenerative ataxia disorders,[8] migraine headaches,[8] lateral
medullary syndrome, Chiari malformation,[8] multiple sclerosis,[8] parkinsonism, as well as
cerebral dysfunction.[17] Central vertigo may not improve or may do so more slowly than vertigo
caused by disturbance to peripheral structures.[17]
Signs and symptoms

Vertigo is a sensation of spinning while stationary.[22] It is commonly associated with nausea or
vomiting,[2] unsteadiness (postural instability),[20] falls,[23] can affect a person's thoughts, and
difficulties in walking.[24] Recurrent episodes in those with vertigo are common and frequently
impair the quality of life.[4] Blurred vision, difficulty in speaking, a lowered level of
consciousness, and hearing loss may also occur. The signs and symptoms of vertigo can present
as a persistent (insidious) onset or an episodic (sudden) onset.[25]
Persistent onset vertigo is characterized by symptoms lasting for longer than one day[25] and is
caused by degenerative changes that affect balance as people age. Naturally, the nerve
conduction slows with aging and a decreased vibratory sensation is common.[26] Additionally,
there is a degeneration of the ampulla and otolith organs with an increase in age.[27] Persistent
onset is commonly paired with central vertigo signs and systems.[25]
The characteristics of an episodic onset vertigo is indicated by symptoms lasting for a smaller,
more memorable amount of time, typically lasting for only seconds to minutes.[25] Typically,
episodic vertigo is correlated with peripheral symptoms and can be the result of but not limited to
diabetic neuropathy or autoimmune disease.
Motion sickness
Motion sickness is one of the most prominent symptoms of vertigo and develops most often in
persons with inner ear problems. The feeling of dizziness and lightheadedness is often
accompanied by nystagmus (an involuntary movement of the eye characterized by a smooth
pursuit eye movement followed by a rapid saccade in the opposite direction of the smooth
pursuit eye movement). During a single episode of vertigo, this action will occur repeatedly.
Symptoms can fade while sitting still with the eyes closed.
Diagnostic approach
Tests for vertigo often attempt to elicit nystagmus and to differentiate vertigo from other causes
of dizziness such as presyncope, hyperventilation syndrome, disequilibrium, or psychiatric
causes of lightheadedness.[12] Tests of vestibular system (balance) function include:
electronystagmography (ENG),[12] Dix-Hallpike maneuver,[12] rotation tests, head-thrust test,[8]
caloric reflex test,[8][28] and computerized dynamic posturography (CDP).[29] CT scans or MRIs
are sometimes used by physicians when diagnosing vertigo.[2]
Tests of auditory system (hearing) function include pure tone audiometry, speech audiometry,
acoustic reflex, electrocochleography (ECoG), otoacoustic emissions(OAE), and the auditory
brainstem response test.[29]
A number of specific conditions can cause vertigo. In the elderly, however, the condition is often
multifactorial.[4]
Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder[9] and
occurs when loose calcium carbonate debris has broken off of the otoconial membrane and enters
a semicircular canal thereby creating the sensation of motion.[8][12] Patients with BPPV may
experience brief periods of vertigo, usually under a minute,[8] which occur with change in
position.[30] It is the most common process of vertigo.[4] It occurs in 0.6% of the population
yearly with 10% having an attack during their lifetime.[4] It is believed to be due to a mechanical
malfunction of the inner ear.[4] BPPV may be diagnosed with the Dix-Hallpike test and can be
effectively treated with repositioning movements such as the Epley maneuver.[4][11][30][31]
Vestibular migraine
Vestibular migraine is the association of vertigo and migraines and is one of the most common
causes of recurrent, spontaneous episodes of vertigo.[4][9] The etiology of vestibular migraines is
currently unclear;[9] however, one hypothesized cause is that the stimulation of the trigeminal
nerve leads to nystagmus in individuals suffering from migraines.[12] Other suggested causes of
vestibular migraines include the following: unilateral neuronal instability of the vestibular nerve,
idiopathic asymmetric activation of the vestibular nuclei in the brainstem, and vasospasm of the
blood vessels supplying the labyrinth or central vestibular pathways resulting in ischemia to
these structures.[2] Vestibular migraines are estimated to affect 1-3% of the general
population[4][12] and may affect 10% of migraine patients.[12] Additionally, vestibular migraines
tend to occur more often in women and rarely affect individuals after the sixth decade of life.[9]
Mnire's disease
Mnire's disease is a vestibular disorder of unknown origin, but is thought to be caused by an
increase in the amount of endolymphatic fluid present in the inner ear (endolymphatic
hydrops).[12] However, this idea has not been directly confirmed with histopathologic studies but
electrophysiologic studies have been suggestive of this mechanism.[32] Mnire's disease
frequently presents with recurrent, spontaneous attacks of severe vertigo in combination with
ringing in the ears (tinnitus), a feeling of pressure or fullness in the ear (aural fullness), severe
nausea or vomiting, imbalance, and hearing loss.[8][25][32] As the disease worsens, hearing loss
will progress.

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Vertigo is classified into either peripheral or central depending on the location of the dysfunction

of the vestibular pathway,[15] although it can also be caused by psychological factors.[16]

Signs and symptoms

Benign paroxysmal positional vertigo

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