Unifying Concepts

Differential Diagnosis of Acute Vertigo

Benign paroxysmal positional vertigo (BPPV) is characterized by brief spinning sensations, usually lasting less than 1 minute, which are generally induced by a change in head position with respect to gravity.

BPPV must be distinguished from other, more serious causes of acute or episodic vertigo. A history taking and neurologic examination often allow for differentiation among stroke, vestibular neuritis, and BPPV.

Differential Diagnosis of Acute Vertigo

Cause Onset and Course Nystagmus Auditory Symptoms Other Features
BPPV* Recurrent, transient, positional; usually provoked by turning over or getting in and out of bed Positional, with mixed vertical torsional nystagmus in BPPV involving posterior canal and horizontal nystagmus in BPPV involving horizontal canal None Recent inciting event possible (e.g., recumbent position at dentist’s office or hair salon, prolonged bed rest, head trauma); history of similar episodes
Stroke Spontaneous, usually sustained; may be worsened by positional change Spontaneous, with beating in various or changing directions Occasional Neurologic symptoms or signs may include headache and vertical misalignment of eyes; results of head impulse test typically normal†
Vestibular neuritis Spontaneous, sustained; may be worsened by positional change Spontaneous, predominantly horizontal None May be preceded by viral illness; results of head-impulse test abnormal†
Vestibular migraine Recurrent, spontaneous; duration for minutes to hours; may be positional Rare, but when present usually positional Occasional Migrainous headaches, motion sickness, family history
Meniere’s disease Recurrent, spontaneous; typical duration for hours Spontaneous, horizontal Fluctuating hearing loss, tinnitus Ear pain, sensation of fullness in ear

* BPPV denotes benign paroxysmal positional vertigo.

† In the head-impulse test, the result is considered abnormal when a corrective movement (saccade) is required to maintain straight-ahead fixation after the head has been rotated to the side.



  1. Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014 Mar 20;370(12):1138-47 [Medline]
  2. von Brevern M. Benign paroxysmal positional vertigo. Semin Neurol. 2013 Jul;33(3):204-11. [Medline]


Created Jul 23, 2014.

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