Benign Paroxysmal Positional Vertigo Differential Diagnoses

Updated: Jan 14, 2022
  • Author: John C Li, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Diagnostic Considerations

Differential diagnoses for benign paroxysmal positional vertigo (BPPV) can be divided into 3 main areas of pathology: labyrinthine, vestibular nerve, and central sites of lesions. These are subdivided further as follows:

  • Ménière disease is probably the most frequent misdiagnosis applied to chronic BPPV because patients may fail to recognize the positional provocation. It is also confusing because BPPV can occur concomitantly.

  • Inner ear concussion may cause transient positional vertigo and nystagmus and can be confused with BPPV.

  • Alcohol intoxication can cause positional nystagmus, is persistent in a given position, and varies according to head position.

  • With labyrinthitis, the nystagmus is spontaneous, persistent, predominantly linear-horizontal and affected little by head position. Caloric testing often reveals unilateral weakness.

  • For vascular loop syndrome, the diagnostic criteria have been defined poorly. This diagnosis should be considered only after all other possibilities are exhausted.

  • Positional nystagmus of central origin is seldom transient and may be down-beating, whereas BPPV is usually up-beating. Frequently, other CNS signs are present.

  • Positional down-beating nystagmus is often associated with a lesion of the nodulus (which normally inhibits vertical vestibuloocular reflex gain) from stroke, multiple sclerosis, Arnold-Chiari malformation, ischemia, cerebellar degeneration, and intoxication.

  • Central positional nystagmus may indicate a posterior fossa lesion such as acoustic neuroma or meningioma.

  • Vertebral artery insufficiency is also a differential diagnosis for BPPV.

  • Cervical vertigo, or head extension vertigo, is a somewhat ill-defined entity of symptoms that arises with head extension, quite possibly a manifestation of vascular compression (vertebral arteries).

  • With orthostatic hypotension, low blood volume or poor systemic arterial tone can account for hypoperfusion of the brain and cause dizziness. Patients feel better when lying down and are symptomatic when sitting up.

Differential Diagnoses