Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

Rare Diagnoses

  • Earwax (Common Problem but Rare Cause of Vertigo)
  • Syphilis
  • Acoustic Neuroma
  • Nasopharyngeal Carcinoma
  • Post-Traumatic

Ready Reckoner

Key distinguishing features of the most common diagnoses

Benign PositionalVestibular MigraineMénière’sVestibular NeuritisET Dysfunction
Rapid Onset, SeverePossiblePossibleYesPossibleNo
Associated Viral IllnessNoNoNoYesPossible

Possible Investigations

  • There are no investigations likely to be performed in primary care. Referral might lead to a number of secondary care tests, such as audiometry for cochlear function; electronystagmography, calorimetry and brainstem-evoked responses to assess vestibular function; CT or MRI scan for possible neurological conditions; EEG for suspected epilepsy; lumbar puncture in possible MS; and syphilis serology if syphilis is suspected.

Top Tips

  • Take a careful history – the patient may use the term ‘vertigo’ inaccurately, or describe true ‘vertigo’ as light-headedness. The diagnostic possibilities for vague dizziness and true vertigo are quite different.
  • The vast majority of cases seen in primary care are benign positional vertigo, vestibular migraine, Ménière’s disease or viral neuritis.
  • Ménière’s disease tends to be over-diagnosed. It comprises violent paroxysms of vertigo lasting for several hours, associated with deafness and tinnitus, often necessitating urgent attention because of prostration and vomiting.
  • Benign positional vertigo is usually easily diagnosed by the history – the patient experiences vertigo lasting only for a few seconds, classically on turning over in bed.
  • Vestibular migraine is under-diagnosed. Consider it in any case of recurrent vertigo – enquire about headache before, during or after the vertigo.

Red Flags

  • The patient who has chronic otitis media and then develops vertigo probably has significant disease – especially if the fistula sign is positive (putting pressure on the external ear canal by forcibly occluding the external auditory meatus with a finger causes vertigo). Refer urgently.
  • Young or middle-aged patients with atypical, episodic vertigo who have other, diffuse and transient neurological symptoms may have MS.
  • Loss of consciousness with vertigo suggests epilepsy.
  • An acoustic neuroma can cause quite mild vertigo. Consider this possibility if the patient also has a unilateral sensorineural deafness and tinnitus.
  • A neurological cause such as a stroke is suggested by any CNS symptoms or signs; a new type of headache, especially occipital; acute deafness (otherwise unexplained); or vertical nystagmus.
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