Vertigo, an unexpected feeling of self-motion, is no longer characterized simply by symptom quality but by using triggers and timing. Evaluating vertigo by triggers and timing not only distinguishes serious central causes from benign peripheral causes, but also narrows the differential diagnosis by further classifying vertigo as spontaneous episodic vestibular syndrome, triggered episodic vestibular syndrome, or acute vestibular syndrome. A targeted physical examination can then be used to further delineate the cause within each of these three vestibular categories. Neuroimaging and vestibular testing are not routinely recommended. In the management of vertigo, vestibular hypofunction can be treated with vestibular rehabilitation, which can be self-administered or directed by a physical therapist. Pharmacotherapy sometimes is indicated for vertigo based on triggers, timing, and the specific condition, but it is not always beneficial and is used more often for symptom reduction than as a cure. Transtympanic corticosteroid or gentamicin injections are recommended for patients who do not benefit from nonablative therapy. Surgical ablative therapy is reserved for patients who have not benefited from less definitive therapy and have nonusable hearing.

Case 2. AS is a 46-year-old otherwise healthy patient who reports the acute onset of frequent, severe episodes of dizziness with associated nausea and vomiting. The dizziness is characterized by a nearly constant sensation of spinning, and she describes leaning or being pulled to the right side primarily when walking, consistent with vertigo. AS says keeping her head still at times can almost resolve the vertigo. Head movement worsens the vertigo but does not necessarily trigger it. On questioning, she recalls having some upper respiratory symptoms the week before the vertigo started.