From the Guidelines
The main differentiating factors between central and peripheral vertigo are the nature of symptoms, associated neurological signs, and duration of episodes, with peripheral vertigo typically presenting with sudden, intense spinning sensations and central vertigo often presenting with a less severe, more constant sense of imbalance or lightheadedness. The key characteristics of peripheral vertigo include:
- Sudden, intense spinning sensations
- Often accompanied by nausea, vomiting, and unilateral hearing loss or tinnitus
- Usually triggered by head movements
- Episodes are generally short-lived, lasting seconds to minutes, but may recur frequently In contrast, central vertigo is characterized by:
- A less severe, more constant sense of imbalance or lightheadedness
- Typically not affected by head position
- May persist for days or weeks
- Often accompanied by other neurological symptoms such as double vision, slurred speech, or limb weakness
- Nystagmus can be vertical, torsional, or bidirectional, and the presence of purely vertical nystagmus strongly suggests central vertigo 1. Additionally, patients with peripheral vertigo can often suppress their nystagmus by visual fixation, whereas those with central vertigo cannot 1. These differences reflect the underlying causes: peripheral vertigo results from inner ear or vestibular nerve dysfunction, while central vertigo stems from issues in the brainstem or cerebellum 1. Some specific conditions that can cause vertigo and their differentiating features include:
- Benign paroxysmal positional vertigo (BPPV): characterized by positional vertigo lasting less than a minute, not associated with hearing loss, tinnitus, or aural fullness 1
- Ménière's disease: characterized by episodes of vertigo lasting between 20 minutes to 24 hours, accompanied by fluctuating hearing loss, tinnitus, and aural fullness 1
- Vestibular migraine: presents with attacks lasting hours, but can also present with attacks lasting minutes or days, often accompanied by photophobia and other migraine symptoms 1
- Stroke or transient ischemic attack: vertigo may last for minutes, often accompanied by other neurological symptoms such as dysphagia, dysphonia, or limb weakness 1.
From the Research
Differentiating Factors between Central and Peripheral Vertigo
The key factors that differentiate central vertigo from peripheral vertigo include:
- The duration of vertigo attacks: vertigo associated with vertebrobasilar insufficiency typically lasts minutes, whereas peripheral inner ear causes of recurrent vertigo typically last hours 2
- Associated symptoms: vertigo of peripheral origin is typically associated with auditory symptoms such as hearing loss and tinnitus, while vertigo of central origin is nearly always associated with neurological symptoms such as diplopia, weakness, numbness, and ataxia 3
- Temporal course: three forms of vertigo syndrome can be differentiated, including vertigo attacks, acute spontaneous vertigo lasting for days, and symptoms lasting for months or years 4
- Positional vertigo: nearly always a benign condition that can be cured easily at the bedside, but in rare cases, it can be a symptom of a central lesion, particularly one near the fourth ventricle 2
- Nystagmus: central positional nystagmus is nearly always purely vertical (either upbeating or downbeating), and there are usually associated neurologic findings 2
Diagnostic Approaches
Diagnostic approaches to differentiate between central and peripheral vertigo include:
- The HINTS examination, which can help differentiate peripheral from central causes of dizziness and vertigo 5
- A systematic approach to diagnose the cause of vertigo, including categorizing dizziness into one of the four groups: lightheadedness, pre-syncope, disequilibrium, and vertigo 6
- Maintaining balance requires sensory inputs from the vestibular, visual, and somatosensory systems, and the cerebellum fine-tunes inaccurate motor outputs 6
Clinical Profiles
Each of the common causes of vertigo has a characteristic clinical profile that should suggest a likely diagnosis after the history and examination are complete, including: