Table 1

Summary of the pathogenesis, history, examination and treatment of the five major causes of new onset vertigo

ConditionBenign paroxysmal positional vertigoVestibular migraineMeniere’s diseaseVestibular neuronitisLabyrinthitisPosterior circulation stroke
PathogenesisAccumulation of crystals in the posterior semi-circular canalsActivation of the trigemino-vestibulocochlear reflexIncreased fluid in the endolymph part of the cochlear and semi-circular canalsInflammation of the vestibular nerveInflammation of the labyrinthHaemorrhage or infarct in the posterior circulation supplying the brainstem and cerebellum
Onset and duration of each episodeSudden onset. Lasts <1 min.Lasts between a few minutes and 72 hoursSudden onset. Lasts hours.Sudden onset. Lasts seconds to minutes.Sudden onset. Lasts seconds to minutes.Sudden or gradual onset. Continuous symptoms.
Duration of illnessSeveral weeks. Can recur later on in life.Episodic or chronicChronicDays to weeksDays to weeksMinutes to days or weeks
Risk factors
  • Most commonly idiopathic

  • Age

  • Head injury/trauma

  • Post-vestibular neuronitis

  • Female

  • Childbearing age

  • Triggers: certain food, stress, lack of sleep

Unknown aetiology
  • Female

  • >40 years old

  • Viral URTI

  • Herpes zoster infection

  • Middle ear infection

  • Viral infection

Cerebrovascular risk factors, ie, HTN, DM, smoking
History and examination findings
  • Change in head position

  • Positional symptoms

  • No HL or tinnitus

  • Dix-hallpike positive

  • Headache

  • Sensory aura

  • Photophobia

  • Phonophobia

  • Ear pain

  • Tinnitus

  • Aural fullness

  • SNHL

  • Tinnitus

  • Aural fullness

  • Nausea and vomiting

  • No HL or tinnitus

  • Head impulse test positive

  • SNHL

  • Tinnitus

  • Head impulse test positive

  • Vertical nystagmus

  • Direction changing

  • Usually present with other neurology

TreatmentEpley’s manoeuvreAcute: Paracetamol, NSAIDs or triptans.
Prophylaxis: Propranolol, amitriptyline.
Vestibular rehabilitation.
Betahistine, diuretics, intratympanic steroid and gentamicin injections.
Last line is surgery.
Anti-emetics, vestibular rehabilitationAnti-emetics, vestibular rehabilitationAcute stroke care (thrombolysis and/or thrombectomy, anti-platelets, anticoagulants, management of risk factors)
  • DM, diabetes mellitus; HL, hearing loss; HTN, hypertension; NSAIDs, non-steroidal anti-inflammatory drugs; SNHL, sensorineural hearing loss; URTI, upper respiratory tract infection.