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Menière’s disease: duration of the attacks from 20 min to 12 hours, low- to medium-frequency sensorineural hearing loss (>30 dB, <2000 Hz) [28 (link)].
Tumarkin’s otolithic crisis (“vestibular drop attacks”). These sudden falls are usually not accompanied by vertigo and occur most often in patients with known Menière’s disease, typically while standing, whereas in VP the attacks occur in any body positions.
Paroxysmal brainstem attacks with vertigo, dysarthria or ataxia (after stroke or in MS) may be difficult to distinguish, as they also respond to low doses of sodium-channel blockers. It was shown that they may be caused by a brainstem lesion due to MS plaques or lacunar infarctions [27 (link)], which also leads to ephaptic discharges of neighboring fibers of the brainstem paths. In such cases the use of MRI with thin brainstem slices is useful for establishing the diagnosis.
Vestibular migraine [26 (link)]: officially the duration of the attacks is 5 min to 72 hours, current or previous history of migraine, most attacks being accompanied by other migrainous symptoms. In vestibular migraine, short spells of vertigo may be induced by changes of head or body position when patients are motion sensitive during an episode of vestibular migraine.
Vertebrobasilar transient ischemic attacks: vertigo frequently occurs in isolation in this condition [33 (link)].
Panic attacks: according to DSM-5, the diagnostic criteria for a panic attack include a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms develop abruptly and reach a peak within minutes: feeling dizzy, unsteady, lightheaded, or faint; nausea or abdominal distress; palpitations, and/or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath or being smothered; feeling of choking; chest pain or discomfort; de-realization or depersonalization; fear of losing control or going insane; sense of impending death; paresthesias; chills or hot flashes. Panic attacks are often longer than typical attacks of VP. It may be helpful to ask the patient which of the symptoms come first to differentiate between the two.
Perilymph fistula: The cardinal symptoms of perilymph fistula (and superior canal dehiscence syndrome) are attacks of vertigo caused by changes in pressure, for example, by coughing, pressing, sneezing, lifting, or loud noises and accompanied by illusory movements of the environment (oscillopsia) and instability of posture and gait with or without hearing disorders. The attacks, which can last seconds to days, may also occur during changes in the position of the head (e.g., when bending over) and when experiencing significant changes in altitude (e.g., mountain tours, flights) [6 ].
Episodic ataxia type 2: the duration of the attacks varies from several minutes to hours and more than 90% of the patients have cerebellar signs, in particular gaze-evoked nystagmus and downbeat nystagmus [20, 40 (link)]. The onset of manifestations after the age of 20 is unusual. The much rarer episodic ataxia type 1 is another differential diagnosis. It is characterized by recurrent attacks of ataxia, dizziness and visual blurring, provoked by abrupt postural changes, emotion, vestibular stimulation and lasting minutes. These patients also have neuromyotonia, i.e. continuous spontaneous muscle fiber activity [19 (link)].
Epilepsy with vestibular aura: Vestibular auras can manifest with short attacks of vertigo and nystagmus. Vestibular aura with additional symptoms, so-called non-isolated vestibular aura, is much more prevalent than isolated vestibular aura, which is rare. Vestibular aura is primarily associated with temporal lobe seizures. Isolated vestibular aura spells often last only a few seconds, but longer spells are also reported [41 (link)].