J Neurol (2014) 261:229231

DOI 10.1007/s00415-013-7190-x

LETTER TO THE EDITORS

Five keys for diagnosing most vertigo, dizziness, and imbalance

syndromes: an expert opinion
Thomas Brandt Michael Strupp Marianne Dieterich

Received: 18 October 2013 / Revised: 7 November 2013 / Accepted: 8 November 2013 / Published online: 30 November 2013
 Springer-Verlag Berlin Heidelberg 2013

Dear Sirs,
The International Barany Society for Neuro-Otology
recently published a consensus document on how to classify vestibular disorders: vertigo is the sensation of selfmotion when no self-motion is occurring; dizziness is the
sensation of disturbed or impaired spatial orientation
without a false or distorted sense of motion; and imbalance
or unsteadiness is the feeling of being unstable while
seated, standing, or walking without a particular directional
preference [1]. A diagnosis of vertigo, dizziness, and
imbalance syndromes requires first of all a careful patient
history. On the basis of our experience in the German
Center for Vertigo and Balance Disorders, we find that five
different categories with the following key symptoms
provide a reliable and practical diagnostic guide for the
general neurologist and others who manage dizzy patients:
1.

2.
3.

Paroxysmal positional vertigo

(benign paroxysmal positional vertigo [ central
positional vertigo and/or nystagmus)
Spontaneous recurrent vertigo attacks
(vestibular migraine or Menie`res disease)
Sustained rotational vertigo
(vestibular neuritis or central pseudo-neuritis)

4.

5.

In our practice, these five categories cover ten distinct

vertigo, dizziness, or balance disorders that together make
up 8090 % of the diagnoses established in outpatients
who presented at our multidisciplinary dizziness unit
(Table 1; [2]). Once a patient has been assigned to one of
the five syndromic categories, further differentiation of the
ten underlying disorders is based on the following:

M. Strupp
M. Dieterich
Department of Neurology and German Center for Vertigo and
Balance Disorders, Ludwig-Maximilians University,
Marchioninistr. 15, 81377 Munich, Germany

type of vertigo,
duration of attacks (min./max.),
frequency of attacks,
triggers/modulating factors,
associated symptoms.

To determine the presence of the above additional

symptoms, the physician must simply ask the patient the
right questions. The answers will suggest the diagnosis,
which is then confirmed by an oto-neurological examination revealing typical signs (e.g., nystagmus or other ocular
motor abnormalities).
1.

T. Brandt (&)
Institute for Clinical Neurosciences and German Center for
Vertigo and Balance Disorders, Ludwig-Maximilians University,
Marchioninistr. 15, 81377 Munich, Germany
e-mail: thomas.brandt@med.uni-muenchen.de

Frequent spells of dizziness or imbalance

(vestibular paroxysmia [ superior canal dehiscence
syndrome)
Postural imbalance without other neurological
symptoms
(phobic postural vertigo [ bilateral vestibulopathy)

Paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is characterized by rotatory vertigo lasting \1 min. It is the most
frequent vertigo syndrome and is elicited by head movements relative to gravity in the plane of the affected
semicircular canal (posterior, pBPPV [ horizontal,
hBPPV [ anterior, aBPPV) [3]. The resulting vertigo is
associated with positional nystagmus and sometimes with

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J Neurol (2014) 261:229231

Table 1 Ten distinct disorders of vertigo or dizziness listed by their

frequency of occurrence among more than 17,000 outpatients seen in
a multidisciplinary dizziness unit [2]
Benign paroxysmal positional vertigo

*17 %

Phobic postural vertigo

*15 %

Vestibular migraine
Menie`res disease

*11 %

Vestibular neuritis

*8 %

Bilateral vestibular failure

*7 %

Central pseudo-neuritis
Vestibular paroxysmia

*6 %
*4 %

*10 %

Central positional vertigo and/or nystagmus

*3 %

Superior canal dehiscence syndrome

\1 %

Others or unknown

*15 %

nausea. Occasionally, the physician cannot elicit the attack

or nystagmus during the examination. Then the patient
history will help diagnose a probable BPPV [3].
Central positional vertigo (with or without nystagmus)
or central positional nystagmus (without vertigo) may
occur as separate disorders. They last longer than BPPV
(sometimes as persisting positional nystagmus). The physician can consistently elicit them by moving the patients
head into a particular position. This final head position
rather than the head movement as in BPPV triggers the
attack. The nystagmus is often purely torsional or vertical,
and its direction does not correspond to the plane of the
canal stimulated by the head movement [4]. In BPPV, in
contrast, the direction of nystagmus does correspond. Both
central positional vertigo and central positional nystagmus
are caused by vestibulo-cerebellar dysfunction, particularly
of the nodulus or the flocculus.
2.

Spontaneous recurrent vertigo attacks

Vestibular migraine may cause rotatory vertigo or

rocking dizziness. The majority of these attacks last minutes to hours (rarely shorter or longer), and they vary in
frequency, occurring up to several times a month or week.
It is the form of spontaneous episodic vertigo most commonly seen. Sometimes it is elicited by the same triggers
that induce migraine headaches. The affected patients often
report associated migraine symptoms such as headache,
phonophobia, and photophobia. About one-half display
mild central ocular motor disorders in between the attacks,
which are exacerbated with additional postural imbalance
and motion sensitivity during the attacks [5].
Typical attacks of Menie`res disease consist of rotatory
vertigo lasting 20 min to several hours. Menie`res disease
has a frequency of up to several attacks per week or month.
It occurs without any noticeable triggers. The attacks are
often associated with aural fullness of the affected ear,
fluctuating hearing loss, tinnitus, and nausea [6]. Vestibular

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drop attacks (Tumarkins otolithic crisis) are sudden,

recurring falls that happen with no loss of consciousness in
37 % of patients in the early or late stages of Menie`res
disease.
3.

Sustained rotational vertigo

Vestibular neuritis (acute partial unilateral vestibular

deficit) manifests with sudden, violent rotatory vertigo,
which lasts for a few days. Associated signs and symptoms
are spontaneous nystagmus, illusory movements of the
surroundings (oscillopsia), gait and postural imbalance
with a tendency to fall to the affected ear, nausea, and
vomiting. Acute hearing disorders, tinnitus, or other neurological deficits are not part of the clinical picture. The
head-impulse test and caloric irrigation confirm the unilateral functional deficit of the horizontal canal.
Central pseudo-neuritis also manifests with rotatory
vertigo that lasts for hours to days. It is differentiated from
vestibular neuritis by a normal head-impulse test in the
majority of cases and the presence of central ocular motor
disorders, such as skew deviation (vertical divergence of
the eyes), central fixation nystagmus, gaze-evoked nystagmus in the opposite direction to that of spontaneous
nystagmus, and saccadic smooth pursuit [79]. Both vestibular neuritis as well as central pseudo-neuritis due to
partial infarctions of the posterior inferior cerebellar artery,
to plaques in multiple sclerosis, or to lacunar infarctions at
the root entry zone of the eighth nerve are usually single
events that seldom recur.
4.

Frequent spells of dizziness or imbalance

Vestibular paroxysmia (due to neurovascular crosscompression of the eighth nerve) [10, 11] is characterized
by brief attacks of rotatory or rarely postural vertigo. The
attacks last seconds to a few minutes and occur in series of
up to 30 per day. Sometimes certain head positions or
hyperventilation can trigger the attacks; however, strictly
speaking, vestibular paroxysmia could also be understood
as a spontaneous recurrent vertigo attack. Spells of
vertigo or dizziness may occur with or without tinnitus and/
or hypoacusis.
Superior canal dehiscence syndrome [12, 13] is also
characterized by short, rotatory, rocking, or postural vertigo attacks with oscillopsia. They are generally induced by
changes of pressure, for example when coughing or
pressing, and sometimes by loud sounds (Tullio
phenomenon).
5.

Postural imbalance
symptoms

without

other

neurological

Phobic postural vertigo is a subjective postural dizziness

and imbalance that takes a chronic course, lasting at least
for a period of weeks to months. Often it occurs with short

J Neurol (2014) 261:229231

exacerbations triggered by head movements, social situations, or visual motion stimulation. It improves with sport
activities or small amounts of alcohol. The dissociation of
subjective instability and normal balance function is an
important finding in neurological tests [14]. There are other
terms for chronic subjective vertigo or dizziness syndromes, which have been referred to as, for example,
visually induced vertigo [15].
Bilateral vestibulopathy is also a chronic condition. Its
most common symptom is unsteadiness of posture and gait,
especially in the dark and on unlevel ground. Motion of
head and body (also during transportation in vehicles)
triggers dizziness, imbalance, and oscillopsia. A pathological head-impulse test and caloric hyporesponsiveness
confirm the bilateral peripheral vestibular deficit [16].
Except for these vestibular dysfunctions, there are no
neurological deficits.
Other neurological disorders that manifest with postural
imbalance such as progressive supranuclear palsy, normal
pressure hydrocephalus, or polyneuropathy are not described here because their diagnosis is based on additional
non-vestibular neurological signs and symptoms.
Acknowledgments We thank Judy Benson for copy-editing the
manuscript. The work was supported by the German Ministry of
Education and Research and the Hertie Foundation.
Conflicts of interest
interest.

The three authors declare no conflict of

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