The symptom dizziness is often accompanied by various other symptoms:
- Nausea
- Nystagmus – involuntary but rapid rhythmic eye movements.
- Positional instability
- Gait ataxia (gait disorders)
Type of vertigo
- Systematic vertigo (directional vertigo).
- Continuous vertigo
- Spinning dizziness
- Altitude vertigo
- Positional vertigo
- Positional vertigo
- Elevator vertigo
- Sway vertigo
- Unsystematic vertigo (undirected vertigo, diffuse vertigo).
Meniere’s disease
The following symptoms and complaints may indicate Meniere’s disease:
Leading symptoms (Meniere’s triad).
- Acute onset of spinning/vomiting dizziness with nausea (sickness)/vomiting.
- Unilateral tinnitus (ringing in the ears).
- Sensorineural hearing loss (< 2,000 Hz, at least -30 dB).
Associated symptoms
- Diplakusis – the sounds are perceived higher or lower in the affected ear.
- Pressure/fullness sensation in the affected ear
- Nystagmus – involuntary rhythmic eye movements (eye tremor).
The vertigo usually lasts from minutes (> 20 min.) to 12 hours and repeats at irregular intervals.
Benign paroxysmal positional vertigo
The following symptoms and complaints may indicate benign paroxysmal positional vertigo (BPLS; synonym: benign peripheral paroxysmal positional vertigo (BPPV)):
Leading symptoms
- Spinning attacks of vertigo lasting no longer than 30 seconds (1 min) (when lying down, when turning the head, when looking up or down; frequent occurrence at night)
Associated symptoms
- Nausea may occur in addition
- Oscillopsia (illusory movements of the environment) may additionally occur
Neuritis vestibularis (NV)
The following symptoms and complaints may indicate neuritis vestibularis (NV; synonym: neuropathia vestibularis):
- Constant spinning dizziness, acute onset; may last days to weeks.
- Vertigo is aggravated by turning the head (especially in the morning)
- Ipsilateral fall tendency with stance and gait unsteadiness.
- Nausea (nausea/vomiting)
- Oscillopsia (apparent movements of the environment).
- Nystagmus (involuntary rhythmic eye movements (eye tremor)): directional horizontal rotating spontaneous nystagmus (SPN) to the unaffected side when looking in all directions of gaze.
- Deficit of the vestibulocular reflex (VOR) during head rotation to the affected side when performing the bedside head impulse test of the horizontal arcuate gaze.Note: The VOR, as a brainstem reflex, allows stable visual perception even during sudden head movement.
Hearing is not impaired.
Bilateral vestibulopathy (BV)
The following symptoms and complaints may indicate bilateral vestibulopathy (BV):
- Gait and stance unsteadiness*
- Motion-dependent staggering vertigo
- Oscillopsia (illusory movements of the environment) during head movements.
- Stance insecurity*
- Disturbances of spatial memory
* Increase in the dark and on uneven ground.
Vestibular migraine
Vestibular migraine is the most common cause of recurrent spontaneous attacks of vertigo. The following symptoms and complaints may indicate vestibular migraine:
Diagnostic criteria
| Definite vestibular migraine |
| A. At least 5 episodes of vestibular symptoms (e.g., (spinning or swaying dizziness, unsteadiness of gait, lightheadedness)) of moderate or severe intensity and lasting from 5 minutes to 72 hours |
| B. Active or previous migraine with or without aura according to ICHD criteria* . |
| C. One/more migraine symptoms during at least 50% of vestibular episodes: headache with at least 2 of the following features (unilateral localization, pulsatile character, moderate or severe pain intensity, intensification by routine physical activities): Photophobia and phonophobia and/or visual aura. |
| D. Not due to another vestibular or ICHD diagnosis. |
| Probable vestibular migraine |
| A.At least 5 episodes of vestibular symptoms of moderate or severe intensity and lasting from 5 minutes to 72 hours |
| B. Only one of the two criteria B and C of vestibular migraine applies (history of migraine or migraine symptoms during the attack) |
| C. Not due to another vestibular or ICHD diagnosis. |
* ICHD International Classification of Headache Disorders.
Vestibular paroxysmia
The following symptoms and complaints may indicate vestibular paroxysmia:
- Spinning/vestibular attacks lasting at least 10 seconds to one minute (up to one hundred times per day; at least 10); often without a trigger, but may also be provoked inconstantly by certain head or body positions
Accompanying symptoms (rare)
- Unilateral tinnitus (ringing in the ears).
- Numbness / feeling of pressure in the area of the ear.
- Unilateral hearing loss
Other indications
- The vertigo attacks occur spontaneously and may be triggered in part by head movements or hyperventilation.
Warning signs (red flags)
- Anamnestic information:
- Chronic alcohol consumption
- Otitis media (inflammation of the middle ear), acute and chronic.
- Visual, speech and swallowing disorders or other neurological deficits.
- In patients aged 20 to 40 years with episodic dizziness and vague neurologic symptoms → think of: Multiple sclerosis (MS)
- Gaze direction nystagmus and/or vertical deviation of the axis of both eyes → think of: Brainstem infarction
- Gait ataxia → think of: Transient ischemic attack (TIA) or apoplexy (stroke).
- Syncope (brief loss of consciousness due to reduced blood flow to the brain, usually accompanied by loss of muscle tone).
- Sudden hearing loss (within 72 hours) or progressive (rapidly progressing) symptomatology
- With /without sudden hearing loss (sudden onset, unilateral, near-total hearing loss) → think of: Acoustic neuroma