What is the treatment approach for central vertigo?

Treatment of Central Vertigo

Central vertigo requires immediate identification of the underlying CNS pathology and treatment directed at the specific etiology—symptomatic vestibular suppressants play only a limited, short-term role while the primary neurological condition is being addressed. 1, 2

Immediate Diagnostic Priorities

Central vertigo demands urgent evaluation because it often signals serious CNS pathology including stroke, hemorrhage, or mass lesions that require specific interventions rather than symptomatic management. 3, 2

Key Clinical Features Distinguishing Central from Peripheral Vertigo

• Nystagmus patterns that indicate central pathology: downbeating nystagmus on Dix-Hallpike (particularly without torsional component), direction-changing nystagmus without head position changes, gaze-evoked nystagmus, or baseline nystagmus without provocative maneuvers. 3
• Associated neurological deficits: dysarthria, dysmetria, dysphagia, sensory or motor loss, Horner's syndrome, gait dysfunction, speech abnormalities, or autonomic dysfunction strongly suggest central causes. 3, 1
• Timing characteristics: vertebrobasilar insufficiency typically causes vertigo lasting minutes, whereas peripheral causes typically last hours. 4

Imaging Requirements

• MRI with DWI is the diagnostic modality of choice for suspected central vertigo, particularly when evaluating for brainstem or cerebellar stroke, which can masquerade as peripheral vestibular disorders. 3, 5
• Urgent MRI of brain and posterior fossa is indicated for patients with acute vertigo and profound imbalance, atypical nystagmus patterns, or associated neurological symptoms. 3, 6
• CT has very low yield (approximately 2% positivity rate) in emergency department patients with dizziness, though it may detect hemorrhage or mass lesions. 3

Etiology-Specific Treatment Approaches

Brainstem or Cerebellar Stroke

• Acute stroke protocols take precedence: thrombolysis or thrombectomy within appropriate time windows for ischemic stroke, neurosurgical consultation for hemorrhagic stroke or cerebellar infarction with mass effect. 3, 6
• Cerebellar stroke is particularly dangerous—10% of cerebellar strokes present similarly to peripheral vestibular processes, and early recognition is critical to prevent herniation. 3

Vestibular Migraine

• Diagnostic criteria must be met: ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, current or history of migraine, ≥1 migraine symptom during at least 50% of dizzy episodes (migrainous headache, photophobia, phonophobia, visual aura), with other causes ruled out. 3
• Treatment follows migraine management principles with prophylactic medications and acute abortive therapy. 3

Multiple Sclerosis and Demyelinating Disease

• Disease-modifying therapies and corticosteroids for acute exacerbations are the primary treatments, not vestibular suppressants. 3, 2

Intracranial Tumors

• Neurosurgical evaluation and treatment (resection, radiation, chemotherapy depending on tumor type) address the underlying cause. 3

Autoimmune Vestibulocerebellar Syndromes

• Specific antibody testing is now available, and immunotherapy may be indicated for confirmed autoimmune etiologies. 2

Limited Role of Symptomatic Medications

Vestibular Suppressants

• Meclizine and other vestibular suppressants should NOT be used as primary treatment for central vertigo because they mask symptoms without addressing the underlying CNS pathology. 7, 8
• Short-term use (days, not weeks) may be considered only for severe nausea/vomiting while definitive treatment is initiated. 8, 1
• Long-term vestibular suppressants interfere with central compensation mechanisms and can prolong symptoms, increase fall risk (especially in elderly), and cause drowsiness and cognitive deficits. 7, 8

Alternative Symptomatic Options

• Prochlorperazine may be more effective than meclizine for managing severe nausea associated with vertigo. 7
• Benzodiazepines can be considered short-term for severe vertigo with anxiety component, but carry similar risks of delayed compensation. 7

Vestibular Rehabilitation Considerations

• Vestibular rehabilitation therapy is generally NOT appropriate for acute central vertigo until the underlying CNS pathology is identified and treated. 8, 1
• Once the primary neurological condition is stabilized, vestibular rehabilitation may help with residual balance dysfunction. 7, 8

Critical Management Pitfalls

• Failure to recognize central vertigo masquerading as peripheral vertigo: cerebellar infarction can present with vertigo and imbalance as the only features, and vertebrobasilar stroke may mimic vestibular neuritis or Menière's disease. 6, 4
• Treating with vestibular suppressants without proper diagnosis: this delays recognition of serious CNS pathology and interferes with compensation. 3, 7
• Assuming normal examination between episodes means benign pathology: patients with recurrent central vertigo may have normal examinations between attacks, requiring careful attention to attack duration and associated symptoms. 4

Follow-Up Requirements

• Reassessment within 1 month is essential for any patient with persistent vertigo symptoms to identify treatment failures or evolving CNS pathology. 8
• Patients with atypical features, refractory symptoms after 2-3 treatment attempts, or associated auditory/neurological symptoms require thorough neurological examination and MRI. 3