Timing & duration

Think of vertigo by the clock. Spells that last only seconds and are set off by moving the head point to BPPV. Attacks lasting hours, with hearing symptoms, suggest Ménière's disease. A single bout lasting days points to vestibular neuritis. And feeling dizzy nearly every day for months suggests a chronic, often functional, cause.

Clarify the time of the first attack, the duration and course of subsequent attacks, whether symptoms are constant or intermittent, and whether there are symptom-free intervals. Brief attacks of seconds to minutes, evoked by head movement relative to gravity, are highly suggestive of BPPV.1 Attacks of 20 minutes to several hours with fluctuating hearing, tinnitus, and aural fullness meet the durational criterion for Ménière's disease.2

Vertigo lasting hours to days at fixed intensity is typical of the acute vestibular syndrome — most often vestibular neuritis. Persistent daily symptoms over more than three months point to PPPD or another chronic vestibular syndrome.3

The Bárány Society taxonomy maps cleanly onto duration: the episodic vestibular syndrome (recurrent, self-limited — BPPV, Ménière's, vestibular migraine), the acute vestibular syndrome (sudden, sustained — neuritis vs stroke), and the chronic vestibular syndrome (persistent — PPPD, bilateral vestibulopathy, central degenerations). Each has its own differential, examination strategy, and red flags.

Vestibular migraine is the great mimic here: its attacks vary from minutes to days and overlap every other category, so timing alone never excludes it — it must be combined with the migrainous features and the longitudinal pattern.