What are the distinguishing features between peripheral vertigo and central vertigo?

From the Guidelines

Distinguishing peripheral from central vertigo is crucial and can be achieved by evaluating specific symptoms and characteristics, with peripheral vertigo typically presenting with intense spinning sensations and significant nausea, whereas central vertigo presents with milder dizziness and minimal nausea, often accompanied by neurological symptoms 1. To differentiate between peripheral and central vertigo, it's essential to consider the patient's symptoms, medical history, and physical examination findings. Peripheral vertigo is often associated with benign paroxysmal positional vertigo (BPPV), vestibular neuritis, and Meniere's disease, and typically presents with:

• Intense spinning sensations
• Significant nausea
• Unilateral hearing loss or tinnitus
• Worsening with head movement
• Improvement with visual fixation
• Resolution within days to weeks
• Horizontal nystagmus with a rotational component, unidirectional, and suppressed by visual fixation

In contrast, central vertigo is often associated with more serious conditions like stroke, multiple sclerosis, or tumors, and typically presents with:

• Milder dizziness
• Minimal nausea
• Neurological symptoms like diplopia, dysarthria, or limb weakness
• No worsening with head movement
• No improvement with fixation
• Persistence for extended periods
• Purely vertical, horizontal, or torsional nystagmus, changing direction with gaze, and not suppressed by visual fixation

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) is a useful tool for differentiating between peripheral and central vertigo, with a normal head impulse test, direction-changing nystagmus, and vertical skew deviation strongly suggesting central pathology requiring immediate neuroimaging 1. Some key points to consider when evaluating patients with vertigo include:

• The Dix-Hallpike maneuver can help diagnose posterior semicircular canal BPPV, which is a common cause of peripheral vertigo 1
• The supine roll test can help diagnose lateral semicircular canal BPPV, another cause of peripheral vertigo 1
• Patients with central vertigo often require immediate neuroimaging to rule out serious conditions like stroke or tumors 1
• The treatment of BPPV, a common cause of peripheral vertigo, involves canalith repositioning procedures, which can significantly improve quality of life 1

From the Research

Distinguishing Peripheral from Central Vertigo

To distinguish between peripheral and central vertigo, several factors and tests can be considered:

• The history of the patient usually provides key information for distinguishing between peripheral and central causes of vertigo 2.
• The duration of attacks can be helpful, as vertigo associated with vertebrobasilar insufficiency typically lasts minutes, whereas peripheral inner ear causes of recurrent vertigo typically last hours 2.
• Positional vertigo is nearly always a benign condition, but in rare cases, it can be a symptom of a central lesion, particularly one near the fourth ventricle 2.
• Central positional nystagmus is nearly always purely vertical and is usually associated with other neurologic findings 2.

Diagnostic Tests

Several diagnostic tests can be used to distinguish between peripheral and central vertigo:

• The Dix-Hallpike test is commonly used to diagnose benign paroxysmal positional vertigo (BPPV), with a sensitivity of 79% and specificity of 75% 3.
• The side-lying test can be used as an alternative to the Dix-Hallpike test, with a sensitivity of 90% and specificity of 75% 3.
• The Epley maneuver is more effective than vestibular rehabilitation in treating posterior BPPV at 1-week follow-up, but there is inconsistent evidence for its effectiveness at 1-month follow-up 4.
• Vestibular rehabilitation in addition to the Canalith Repositioning Maneuver does not appear to influence the positive to negative Dix-Hallpike test, recurrence, or number of maneuvers to achieve a negative test in elderly patients with chronic BPPV 5.

Key Considerations

When evaluating patients with vertigo, it is essential to consider the following:

• A thorough history and physical examination are crucial in distinguishing between peripheral and central causes of vertigo 2.
• Imaging studies, such as MRI, may be indicated in patients with acute vertigo and profound imbalance suspected to be the result of cerebellar infarct or hemorrhage 2.
• The diagnosis and treatment of BPPV can be challenging, and a structured approach to diagnosis and treatment is recommended 3, 4, 5.