Dizziness
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Differential Diagnosis — Main Causes of Vertigo
| Cause | Type | Clinical characteristics | Treatment |
|---|---|---|---|
| BPPV (benign paroxysmal positional vertigo) | Device | Brief vertigo (10–60 sec) + triggered by changes in head position (lying down + standing up + turning head + looking up) + horizontal or rotatory geotropic nystagmus on Dix-Hallpike + latency 5–10 sec + fatigable with repetition + nausea + without hearing loss or tinnitus | Epley maneuver (posterior canalolithiasis — the most common) + effectiveness 80–90% % from the first session + Semont maneuver + barbecue maneuver (horizontal canal) |
| Vestibular neuritis (labyrinthitis) | Device | Intense and prolonged vertigo (days to weeks) + sudden onset + often post-viral + significant nausea and vomiting + gait instability + unidirectional horizontal nystagmus (beating towards the healthy ear) + positive Head Impulse Test + NO hearing loss or tinnitus | Prochlorperazine or meclizine short-term (48–72 hours maximum — vestibular suppression) + vestibular rehabilitation ++ (Cawthorne-Cooksey exercises) + prednisone 1 mg/kg × 5 days (benefit debated) + NO prolonged antivertiginous treatment (delays central compensation) |
| Meniere's disease | Device | Meniere's disease: episodic vertigo + fluctuating sensorineural hearing loss + unilateral tinnitus + aural fullness (blocked ear) + episodes lasting 20 minutes to 12 hours + relapsing-remitting course + endolymphatic hydrops | Low-sodium diet (<2g NaCl/day) + diuretics (hydrochlorothiazide + acetazolamide) + betahistine (Serc® - effectiveness debated) + intratympanic gentamicin or corticosteroid injections + surgery (vestibular neurectomy + labyrinthectomy) for refractory cases |
| Acoustic neuroma (vestibular schwannoma) | Peripheral / Central | Progressive unilateral hearing loss + unilateral tinnitus + instability + rare vertigo (progressive adaptation) + possible facial nerve involvement if large + MRI essential for unexplained unilateral hearing loss | Surveillance (small tumors) + stereotactic radiosurgery (Gamma Knife) + surgery |
| Cerebellar or brainstem stroke | Central - EMERGENCY | Sudden vertigo + central nystagmus (variable direction + vertical + torsional) + abnormal HINTS exam (negative Head Impulse Test - absent refixation + multidirectional nystagmus + positive Test of Skew) + severe ataxia + inability to walk alone + focal neurological signs (diplopia + dysarthria + dysphagia) | Urgent brain MRI (CT insufficient in the acute phase of cerebellar strokes) + urgent neurovascular management |
| Vestibular migraine | Functional center | Recurrent vertigo (minutes to hours) + migraine headaches (in 50 % of episodes only) + photophobia + phonophobia + history of migraine + often in young women | Acute treatment: triptan + antiemetic + prophylactic treatment: beta-blockers + topiramate + amitriptyline (depending on migraine profile) |
HINTS - Emergency examination to differentiate peripheral vs. central vertigo
- H - Head Impulse Test (test d'impulsion de la tête): The doctor holds the patient's head and quickly rotates it → in a patient with peripheral vertigo (vestibular neuritis): visible corrective eye catch-up movement (catch-up saccade = refixation) = POSITIVE Head Impulse Test (reassuring - likely peripheral origin) + in a patient with a brainstem stroke: no catch-up saccade = NEGATIVE Head Impulse Test (alarming - possible central origin)
- Nystagmus: Horizontal unidirectional nystagmus (always beating in the same direction regardless of gaze) = peripheral (reassuring) + bidirectional, vertical, or gaze-changing nystagmus = central (alarming)
- TS — Test of Skew : cover-uncover test → vertical deviation of one eye during alternating occlusion = Skew Test POSITIVE = central (alarming) + no deviation = peripheral (reassuring)
- Overall interpretation HINTS: if all 3 signs are «reassuring» (positive HIT + unidirectional nystagmus + negative Test of Skew) → very likely peripheral origin + if at least ONE sign is «alarming» → exclude brainstem or cerebellar stroke → urgent MRI
- Brain CT scan findings superior to in the acute phase: The HINTS exam performed by an experienced clinician has a sensitivity of 100% and a specificity of 96% for detecting a brainstem stroke—superior to cerebral CT (sensitivity 16–20% only in the first hours of a cerebellar stroke)
Epley Maneuver - Posterior Canal BPPV
- Step 1 — Dix-Hallpike Position: Patient assisted + head turned 45° towards the affected ear + rapid supine positioning + head hanging 30° in extension → wait for nystagmus (5–60 seconds)
- Step 2: Hold the position for 30 seconds after the nystagmus disappears
- Step 3: Rotate head 90° towards the healthy ear (head turned 45° towards the healthy side) + hold for 30 seconds
- Step 4: 90° further rotation of the torso and head (patient on the opposite side + head facing the floor) + hold 30 seconds
- Step 5: Return to a seated position slowly
- Efficiency 80–90% % resolution from the first session + can be repeated immediately if incomplete result + can be taught to the patient for self-treatment at home
Call 911 or go to the emergency room immediately if dizziness is accompanied by diplopia (double vision) + dysarthria (slurred speech) + dysphagia (difficulty swallowing) + severe ataxia (inability to walk) + motor or sensory deficit + sudden «thunderclap» headache + or if the patient cannot walk alone — these signs suggest a cerebellar or brainstem stroke requiring urgent MRI and potential thrombolysis. For the diagnosis and outpatient treatment of BPPV (Epley maneuver) and vestibular neuritis, Clinique Omicron offers medical consultations at its service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's doctors and nurse practitioners (NPs) evaluate dizziness through structured history taking and a comprehensive clinical examination (Dix-Hallpike + HINTS + head impulse test), perform the Epley maneuver for BPPV with an 80–90% success rate %, prescribe short-term anti-vertigo medications for vestibular neuritis, immediately refer patients to the emergency room in case of central signs (abnormal HINTS), and follow up on Meniere's disease and vestibular migraine. Consultations are available at several service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not substitute for medical or neurological advice. Any acute vertigo with an abnormal HINTS exam (negative Head Impulse Test + multidirectional nystagmus + positive Test of Skew) should warrant an urgent brain MRI to rule out a brainstem stroke — a CT scan of the brain is insufficient in this context.
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