Introduction

Most people have experienced lightheadedness and dizziness at some point in their lives due to various causes. Vertigo is a specific type of dizziness, which must be differentiated from lightheadedness, disequilibrium, and presyncope. Vertigo manifests as a sensation of motion and spinning, where the affected individual perceives either the world around them or themselves spinning in space, in the absence of actual motion.¹ The underlying causes of vertigo cover a wide range of pathologic conditions of varying severities. It can be categorised into peripheral conditions involving the inner ear or the vestibular nerve; and central conditions involving specific regions of the brain, primarily associated with vestibular disorders. Additionally, psychological factors such as stress and panic attacks have been correlated with vertigo.² Individuals of all ages can experience the distressing symptoms of vertigo, with an increasing incidence observed among the elderly.³

Understanding vertigo and distinguishing it from other forms of dizziness is crucial for receiving appropriate medical aid. Recognising the symptoms and investigating potential causes of vertigo can be beneficial for assessing the nature of this troublesome condition.

Common causes of vertigo

Vertigo can be classified into different subtypes based on the origin of the causes, typically observed within the vestibular system, which can be either peripheral or central.

Peripheral causes

Vertigo is most commonly identified due to peripheral causes such as:⁴

• Benign paroxysmal positional vertigo (BPPV)

BPPV is the most common cause of peripheral vertigo, accounting for approximately 20% of all cases seeking medical help. This condition involves the dislocation of calcium carbonate deposits, known as otoconia, within the semicircular canal of the inner ear. Such displacement affects the balance upon changes in head position. Thus, individuals with BPPV may experience vertigo, typically lasting around 30 seconds, when they tilt or turn their heads⁵

• Ménière’s disease

Ménière’s disease is a rare disorder of the inner ear, typically represented by endolymphatic hydrops, which may result in imbalances in the sense of balance and cause vertigo. Individuals with a documented Ménière’s disease may experience two or more recurrent episodes of sudden vertigo lasting from 20 minutes up to 12 or even 24 hours. Additional aural symptoms may be present, such as hearing loss or tinnitus in the affected ear that cannot be explained by other vestibular conditions⁶

• Labyrinthitis

Labyrinthitis refers to an inner ear infection characterised by the presence of inflammation in the membranous labyrinth of the inner ear, which, along with the vestibular nerves within it, regulates balance and hearing. This condition is commonly triggered by a bacterial or viral infection, although it can also be associated with autoimmune diseases and human immunodeficiency virus. Individuals with labyrinthitis most often experience symptoms such as vertigo, nausea, vomiting, tinnitus, or hearing loss⁷

• Vestibular neuritis

Vestibular neuritis is a disorder of the inner ear, marked by inflammation of the vestibular nerve of the inner ear, which can result in vertigo⁷

• Cholesteatoma: refers to lesions filled with skin cells in the middle ear⁴
• Otosclerosis: involves the abnormal bone growth in the middle ear, which can cause hearing loss and vertigo⁴
• Perilymphatic fistula: head or ear traumas can cause perilymphatic fistula, leading to vertigo and other associated symptoms⁴

Central causes

Additional central aetiological factors contributing to the occurrence of vertigo include:⁴

• Stroke: ischemic or haemorrhagic strokes represent life-threatening conditions, which have been associated with vertigo, and warrant prompt management 
• Tumours: Brainstem glioma, medulloblastoma, and vestibular schwannoma comprise tumours affecting the cerebellum, with the ability to cause hearing loss and vertigo
• Vestibular migraine: people with vestibular migraine often experience headaches localised to one part of the head, resulting in symptoms such as vertigo, along with nausea, vomiting, photophobia, and phonophobia
• Multiple sclerosis: this autoimmune disease can cause damage to the myelin of the vestibular pathways, resulting in vertigo

Other causes

• Psychogenic factors: conditions like anxiety, depression, and somatisation have been linked with vertigo and dizziness. According to data from a treatment program for vertigo or chronic dizziness, patients with psychiatric disorders were more susceptible to developing vertigo-like symptoms and presented higher levels of disability due to dizziness⁸
• Medication-induced: certain medications, including specific anticonvulsant drugs such as phenytoin and salicylates, have been associated with vertigo as a side effect⁴
• Cardiovascular disease: cardiovascular diseases and arrhythmias could be responsible for cardiogenic vertigo, a specific and potentially severe symptom that necessitates proper diagnosis and treatment⁹

Symptoms of vertigo

Vertigo itself is a symptom described as perceiving rotational movement without actual motion. It could signify the presence of an underlying condition that needs to be addressed for alleviating dizziness. Further vertiginous symptoms may vary depending on the underlying cause and could include:⁴

• Nausea and vomiting: these symptoms are not related to a specific aetiology and are often observed in acute attacks of vertigo
• Dizziness: an accurate description of the feeling of dizziness as a spinning sensation is essential for differentiating vertigo from other forms of dizziness
• Imbalance: patients with vertigo due to unilateral peripheral vestibular disorders may lean towards the affected side, while patients with central causes often require assistance while walking
• Hearing loss
• Tinnitus: mostly observed in Ménière’s disease
• Ear fullness
• Nystagmus: patients may display altered vestibular ocular reflexes, demonstrating rapid and uncontrolled eye movements

Diagnosis

Individuals presenting with the symptom of vertigo initially undergo a comprehensive assessment of their medical history and a detailed description of their perception of the symptom. A thorough physical examination, including ear, eye, neurological and cardiovascular examinations may be conducted. Further diagnostic tests aimed at determining the causes of vertigo may include the Dix-Hallpike manoeuvre, orthostatic blood pressure testing, and head impulse tests.²

FAQ’s

What are the main causes of vertigo?

The primary causes of vertigo include peripheral vestibular disorders of the inner ear. Particularly, BPPV and Ménière’s disease are two distinct conditions commonly associated with vertigo.⁴

Is vertigo a sign of serious illness?

While vertigo is most frequently linked to dysfunctions of the inner ear, it can also be indicative of other more serious underlying conditions. The duration of the vertigo episode can be one of the determining factors for identifying its cause. For instance, a sudden episode of vertigo lasting minutes to a few hours, often accompanied by additional symptoms, could be a sign of a transient ischaemic attack. Conditions such as stroke, multiple sclerosis or tumours could also be potential causes of vertigo that require examination by a healthcare professional.⁴

How long will vertigo last?

Depending on the underlying cause of vertigo, its duration may range from a few minutes or last up to days. It can be a sudden attack or a recurrent symptom. It is best to seek medical help for managing vertigo symptoms and identifying the root cause.⁴

Can stress cause vertigo?

Psychological distress, including stress, anxiety, and somatisation, can induce changes in the vestibular system, causing vertigo, and providing unfavourable feedback in its management.⁸

Who can get vertigo?

Vertigo can affect people of any age. Younger individuals with vertigo are mostly diagnosed with middle ear disorders, whereas the elderly may require assistance to prevent falls and other complications.⁴

Summary

In summary, vertigo represents a distinctive symptom of a particular form of dizziness, separate from lightheadedness, disequilibrium, and presyncope. It is described as the perception of a spinning movement, either of the individual experiencing it or the surrounding environment, despite no actual motion occurring. Various diverse causes could result in the occurrence of vertigo, encompassing peripheral vestibular issues. This can predominately manifest in the inner or middle ear, affecting the balance of individuals. Common peripheral causes include BPPV, Ménière’s disease, labyrinthitis, and vestibular neuritis. Moreover, central causes could also be responsible for provoking vertigo, such as stroke, multiple sclerosis, specific tumours, and migraines. Depending on the underlying causes, vertigo may be accompanied by additional symptoms like nystagmus, hearing loss, tinnitus, nausea, and vomiting.

While some episodes of vertigo may be acute and transient and are mostly associated with mild disorders, others could signal more serious, potentially life-threatening conditions. Therefore, seeking medical assistance to determine the nature of vertigo is pivotal, especially in cases of recurrent episodes of vertigo, or when accompanied by additional stroke symptoms. This proactive approach ensures appropriate diagnosis and management, promoting optimal health and well-being.