How do you differentiate between central and peripheral vertigo clinically?

Differentiating Between Central and Peripheral Vertigo Clinically

The key clinical features that differentiate central from peripheral vertigo include nystagmus characteristics, associated neurological symptoms, duration of symptoms, and response to treatment, with central vertigo typically presenting with pure vertical nystagmus, neurological deficits, and lack of response to repositioning maneuvers. 1

Nystagmus Characteristics

• Peripheral vertigo nystagmus: Typically horizontal with a rotatory (torsional) component, unidirectional, suppressed by visual fixation, fatigable with repeated testing, and has a brief latency period before onset 1
• Central vertigo nystagmus: Often pure vertical (upbeating or downbeating) without torsional component, direction-changing without changes in head position (periodic alternating nystagmus), direction-switching with gaze (beats right with right gaze, left with left gaze), and not suppressed by visual fixation 1
• Central nystagmus often persists without modification when tested with repositioning maneuvers, while peripheral nystagmus typically changes or resolves 1

Associated Symptoms

• Peripheral vertigo: Often presents with auditory symptoms (hearing loss, tinnitus, aural fullness), nausea/vomiting, and no other neurological deficits 2
• Central vertigo: Frequently accompanied by additional neurological symptoms such as dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, or Horner's syndrome 1

Timing and Duration

• Peripheral vertigo:
  • BPPV: Brief episodes (seconds to minutes) triggered by specific head positions 2
  • Vestibular neuritis: Acute onset with symptoms lasting days to weeks 2
  • Ménière's disease: Episodes lasting hours with fluctuating hearing loss 2
• Central vertigo:
  • Vertebrobasilar insufficiency: Episodes typically last minutes 3
  • Cerebellar stroke: Sudden onset with persistent symptoms 1

Provocative Factors

• Peripheral vertigo: Often triggered by specific head positions (BPPV) or pressure changes (perilymph fistula, superior canal dehiscence) 1
• Central vertigo: May occur spontaneously or with position changes but typically not consistently reproducible with specific maneuvers 1

Examination Techniques

• Head-impulse test: Normal in central lesions, abnormal (corrective saccade) in peripheral lesions 4
• Dix-Hallpike maneuver: In peripheral causes (BPPV), produces characteristic nystagmus with latency and fatigability; in central causes, may produce immediate, persistent, purely vertical nystagmus 1
• Cover test: Skew deviation (vertical misalignment of eyes) suggests central pathology 4
• Frenzel goggles examination: Helps differentiate peripheral vestibular spontaneous nystagmus from central fixation nystagmus 4

Response to Treatment

• Peripheral vertigo: Often responds to canalith repositioning procedures (for BPPV) or vestibular rehabilitation 1
• Central vertigo: Typically does not respond to these interventions 1

Red Flags for Central Causes

• Downbeating nystagmus on Dix-Hallpike without torsional component 1
• Baseline nystagmus without provocative maneuvers 1
• Severe imbalance with acute vertigo (may indicate cerebellar stroke) 3
• New-onset severe headache with vertigo (may indicate vertebrobasilar stroke or hemorrhage) 1
• Failure to respond to appropriate peripheral vertigo treatments 1

Common Pitfalls to Avoid

• Misdiagnosing cerebellar stroke as vestibular neuritis - approximately 10% of cerebellar strokes can present similar to peripheral vestibular disorders 2
• Overlooking subtle neurological signs that may indicate central pathology 1
• Failing to perform a complete neurological examination in patients with vertigo 5
• Relying solely on symptom description without objective examination findings 5

Remember that a systematic approach using history and targeted examination techniques can differentiate between central and peripheral vertigo in more than 90% of cases 4.