Approach to vertigo: peripheral or central
- Approach to a complaint
Sort vertigo by duration and trigger; in acute continuous vertigo the HINTS exam separates vestibular neuritis from a stroke.
What it is
Vertigo is a false sense of movement, usually spinning. First separate it from presyncope and from disequilibrium. Then classify it by timing and trigger: brief episodes provoked by head position (BPPV), spontaneous episodes lasting minutes to hours (Ménière disease, vestibular migraine, transient ischaemia) or an acute continuous vestibular syndrome lasting days (vestibular neuritis, labyrinthitis or posterior fossa stroke). Peripheral causes are the most common, but central causes are the dangerous ones: a focused exam, with Dix-Hallpike or HINTS as appropriate, and a search for neurological signs make the difference.
Key questions in the history
- Is it spinning, feeling faint or unsteadiness when walking?
- How long does each episode last: seconds, minutes to hours, or continuous for days?
- Is it triggered by head position, standing up, loud sound or pressure?
- Is there hearing loss, tinnitus or aural fullness?
- Headache, photophobia or a history of migraine?
- Double vision, slurred speech, trouble swallowing, weakness, numbness or vascular risk factors?
Causes and classification
- Episodic, triggered by position (seconds): BPPV; distinguish from orthostatic hypotension.
- Episodic, spontaneous (minutes to hours): Ménière disease, vestibular migraine, vertebrobasilar transient ischaemia.
- Acute vestibular syndrome (continuous, days): vestibular neuritis, labyrinthitis (with hearing loss) or cerebellar or brainstem stroke.
- Chronic unsteadiness: vestibular schwannoma, bilateral vestibular hypofunction (ototoxic drugs) and neurological or multifactorial causes.
- Peripheral: one-direction horizontal-torsional nystagmus suppressed by fixation. Central: vertical or direction-changing nystagmus and marked ataxia.
Step-by-step approach
- Distinguish vertigo from presyncope (suggests a cardiovascular cause) and from disequilibrium.
- Classify by timing and trigger: brief positional, spontaneous episodic or continuous.
- Look for neurological signs: cranial nerves, power, sensation, dysmetria and gait.
- If it is brief and positional, do Dix-Hallpike; if positive, treat in the same visit with Epley.
- If it is continuous with nystagmus, apply HINTS: head impulse, type of nystagmus and alternate cover test.
- Check hearing: new hearing loss with acute vertigo suggests labyrinthitis, but it may also be a vascular infarct.
- With any central sign, activate the stroke pathway and order diffusion-weighted MRI.
Differential diagnosis of vertigo
| Cause | Duration | Trigger and associated features | Exam clue |
|---|---|---|---|
| BPPV | Seconds | Rolling over in bed or looking up; no hearing loss | Positive Dix-Hallpike |
| Vestibular neuritis | Days; improves over weeks | Spontaneous, often after a viral illness; no hearing loss | Abnormal head impulse, one-direction nystagmus |
| Labyrinthitis | Days | As neuritis, plus hearing loss and tinnitus | Sensorineural hearing loss |
| Ménière disease | Minutes to hours | Spontaneous attacks with fluctuating hearing loss, tinnitus and fullness | Low-frequency sensorineural hearing loss |
| Vestibular migraine | Minutes to days | Headache, photophobia or aura in some attacks | Normal exam between attacks |
| Cerebellar or brainstem stroke | Continuous | Vascular risk factors, headache, neurological symptoms | Central HINTS, marked ataxia |
| Vestibular schwannoma | Chronic unsteadiness | Progressive one-sided hearing loss and tinnitus | Asymmetric audiogram |
Red flags
- Vertical nystagmus, direction-changing nystagmus or nystagmus not suppressed by fixation.
- A normal head impulse in a patient with continuous vertigo and nystagmus.
- Skew deviation on the alternate cover test.
- Inability to sit or walk unaided.
- Sudden occipital headache or neck pain (possible vertebral dissection).
- Double vision, slurred speech, trouble swallowing, weakness or numbness, especially with vascular risk factors.
Next step / Initial management
- BPPV: repositioning manoeuvre (Epley for the posterior canal); no routine imaging or drugs.
- Vestibular neuritis: antiemetics and vestibular suppressants (antihistamines, benzodiazepines) for a few days only, and early vestibular rehabilitation.
- Suspected central cause: immediate referral to an emergency department with neuroimaging; diffusion-weighted MRI.
- Vertigo with hearing loss (Ménière, labyrinthitis): audiometry and ENT referral, urgent if the hearing loss is sudden.
- Recurrent vertigo without a clear diagnosis, or not responding to repositioning: routine referral to ENT or neurology.
Test yourself
Think of the answer, then tap the question to see it.
A 62-year-old hypertensive man has had continuous vertigo for 10 hours with nausea and nystagmus. The head impulse is normal and there is skew deviation. What do you suspect and do?
A central HINTS pattern: posterior fossa stroke until proven otherwise. Activate the stroke pathway and order diffusion MRI; a normal CT does not rule it out.
A 50-year-old woman has vertigo lasting seconds when lying down and turning to the right. Which test confirms it and what is the treatment?
Right Dix-Hallpike with upbeating torsional nystagmus, with latency and fatigue (posterior canal BPPV). Treat with the Epley manoeuvre.
Which symptoms come with the vertigo attacks of Ménière disease?
Fluctuating sensorineural hearing loss, low-frequency at first, tinnitus and aural fullness, in attacks of minutes to hours.
Why are vestibular suppressants used for only a few days in vestibular neuritis?
Because prolonged use delays central compensation; once nausea is controlled, vestibular rehabilitation begins.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Vertigo in Clinical Practice: Evidence-Based Diagnosis and Treatment (StatPearls Publishing (NCBI Bookshelf), 2025); Central Vertigo (StatPearls Publishing (NCBI Bookshelf), 2024); Benign Paroxysmal Positional Vertigo (StatPearls Publishing (NCBI Bookshelf), 2025); Vestibular Neuronitis (StatPearls Publishing (NCBI Bookshelf), 2023); Labyrinthitis (StatPearls Publishing (NCBI Bookshelf), 2025); Meniere Disease (StatPearls Publishing (NCBI Bookshelf), 2026); Balance Disorders (National Institute on Deafness and Other Communication Disorders (NIDCD), 2018).
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Representative model, for educational purposes only.