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What is vertigo?
Vertigo is either an unpleasant sensation of spatial disorientation or an erroneously perceived movement (spinning/swaying) of the body or the environment. When a patient makes the general, ambiguous statement that he feels dizzy, his medical history should be carefully taken and he should undergo a neuro-ophthalmological and neuro-otological examination. Both are equally important.
Together the patient history and the clinical examination should allow the physician to differentiate between peripheral vestibular, central vestibular, and non-vestibular forms of vertigo.
Further additional laboratory tests are in most cases of less clinical importance.
 


 
Vertigo: a multisensory syndrome

Vertigo is not a specific disease entity but rather a multisensory syndrome. Episodic forms of vertigo with sensations of imbalance are generally caused by acute lesions or functional disorders of the peripheral vestibular or central vestibular systems. Its various symptoms result from a disturbance of the interaction between the different sensory systems which makes possible dynamic spatial orientation (for example, the visual, vestibular, and somatosensory systems).

The typical disorders of perception (vertigo), gaze stabilization (nystagmus), posture control (tendency to fall, ataxia), and autonomic nervous system (nausea) correspond to the four main functions of the vestibular system, which can be attributed to different sites and structures in the brain.


The sensation of vertigo, an unpleasant distortion of static spatial coordinates or a combined illusion of self-motion / surround motion, is the result of a cortical disturbance of spatial orientation. Nystagmus is caused by a direction-specific tone imbalance of the vestibulo-ocular reflex. Postural instability and gait unsteadiness are the consequences of a disturbance of the vestibulospinal reactions. Nausea and vomiting are triggered by chemical activation of the medullary vomiting center.

Patient history

The following are important criteria for differentiating the various syndromes of vertigo. They also serve as the grounds for clinical classification:

a) the type of vertigo, i.e., rotatory vertigo ("as if on a roller coaster") or postural vertigo ("as if on a boat"),

b) the duration, i.e., attacks of rotatory vertigo (from seconds to minutes as in vestibular paroxysmia, from minutes to hours as in Menière's disease or vestibular migraine), attacks of postural vertigo (e.g., brainstem transient ischemic attacks), or persistent postural vertigo (e.g., bilateral vestibulopathy), and

c) the triggering / intensification, for example, during rest (e.g., vestibular neuritis), during changes of the head relative to gravity (e.g., benign paroxysmal positioning vertigo), or specific situations (e.g., phobic postural vertigo).
 

 

  
Forms Rotatory vertigo Postural vertigo
Duration Attacks of vertigo Persistent vertigo
Trigger
(e.g., change of position)		 Yes No
Accompanying symptoms
(e.g., hypacusis, tinnitus, diplopia or ataxia) 		Yes No
Site of origin Peripheral
(labyrinth or vestibular nerve)
  		Central
(brainstem, cerebellum, or rarely the cortex)


The following additional questions check for the presence of any accompanying symptoms: Are there

a) "otogenic symptoms," for example, attack-like intensified tinnitus or hypacusis, which would indicate Menière's disease or could also occur in brainstem ischemia?

b) other potential brainstem symptoms such as diplopia (double vision), dysesthesia of the face or extremities (abnormal sensations), dysphagia (difficulty in swallowing) or dysarthria (imperfect articulation), paralysis, or disturbance of fine motor performance? These symptoms indicate a central lesion (generally in the brainstem).

c) headache (unilateral, bilateral, or primarily nuchal) or a history of migraine? (Headaches can occur with vestibular migraine, but also during brainstem ischemia or hemorrhage of the cerebellum!)

A tendency to fall, nausea, and vomiting have been observed in several types of vertigo and thus are not discriminating signs for the differential diagnosis.
 
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