Initial assessment
When a patient presents with vertigo, this is an extremely common symptom in clinical practice, but also one that can be diagnostically challenging. Vertigo corresponds to an illusory sensation of movement, usually described as spinning of the body or the surrounding environment.
This complaint should be carefully distinguished from other forms of dizziness, such as presyncope, imbalance or a non-specific sensation of light-headedness. This initial distinction is essential, as it helps determine whether the problem is vestibular or related to a different type of condition.
Neurological red flags
Once true vertigo has been confirmed, the clinical priority is to identify neurological red flags.
The presence of focal deficits, dysarthria, diplopia, significant ataxia, inability to walk or altered consciousness should raise suspicion of a central cause, particularly posterior circulation stroke.
In these cases, the approach should be immediate and directed towards urgent assessment, since vertigo may be the only initial manifestation of serious neurological disease.
Secondary causes and mimics
In the absence of red flags, it is important to consider common secondary causes that may mimic vestibular vertigo.
These include recent trauma, ingestion of toxic substances, adverse drug effects, systemic infections and orthostatic hypotension. Identifying these situations helps avoid unnecessary investigation and allows prompt correction of the underlying cause.
Temporal pattern of symptoms
The next step, and one of the most important elements in clinical reasoning, is to characterise the temporal pattern of symptoms.
Vertigo may present as episodic or continuous, and this distinction strongly guides the differential diagnosis. Assessment should determine whether episodes are triggered by head movements, arise spontaneously or correspond to acute-onset continuous vertigo.
Triggered episodic vertigo
When episodes are brief, lasting only seconds, and clearly triggered by head movements, the most likely cause is benign paroxysmal positional vertigo.
This is a very common condition and is usually treatable with repositioning manoeuvres, after clinical confirmation through appropriate positional tests.
Spontaneous episodic vertigo
When episodes occur spontaneously and last minutes to hours, the differential diagnosis mainly focuses on Ménière’s disease and vestibular migraine.
The presence of auditory symptoms, such as fluctuating hearing loss, tinnitus or aural fullness, points towards a labyrinthine cause and is particularly suggestive of Ménière’s disease.
Conversely, when there is a personal history of migraine or association with photophobia, phonophobia or visual aura, vestibular migraine should be strongly considered, as it is now recognised as one of the most common causes of recurrent vertigo.
Acute continuous vertigo
In cases where vertigo is continuous, with sudden onset and persistence over several days, the priority is to differentiate between peripheral and central causes.
Vestibular neuritis is the most common peripheral cause in this setting, characterised by intense vertigo, spontaneous nystagmus and absence of auditory symptoms. When hearing loss and tinnitus coexist, labyrinthitis should be considered.
However, this is also the group with the greatest risk of diagnostic error, since cerebellar stroke may present in a similar way.
Eye examination and nystagmus
Careful clinical observation plays a decisive role, particularly assessment of eye movements and nystagmus.
Certain patterns of oculomotor response allow peripheral and central causes to be distinguished with high accuracy, making this an essential tool in clinical practice, especially when initial imaging tests may be normal.
Persistent postural-perceptual dizziness
In addition to structural vestibular causes, it is important to recognise that vertigo or dizziness may take a persistent, non-spinning form, often associated with visual, postural and emotional factors.
In these cases, persistent postural-perceptual dizziness represents an increasingly recognised functional cause, particularly after an acute vestibular episode.
Summary of the approach
In summary, the clinical interpretation of vertigo follows a logical and progressive sequence: confirm the nature of the symptom, exclude red flags, recognise secondary causes and use the temporal pattern and physical examination findings to guide the differential diagnosis.
This structured approach significantly reduces clinical uncertainty, supports early identification of potentially serious situations and guides appropriate investigation and treatment, promoting consistent and safe decisions in everyday clinical practice.
