How do you differentiate and manage peripheral vs central vertigo?

Differentiating and Managing Peripheral vs Central Vertigo

The most critical first step is to identify red flags for central vertigo through nystagmus characteristics and associated neurological symptoms, as missing a central cause like posterior circulation stroke can be fatal. 1

Initial Clinical Approach: Timing and Triggers Framework

Focus your history on timing (acute vs episodic vs chronic) and triggers (positional vs spontaneous) rather than the patient's descriptive terms for dizziness. 2 This framework categorizes vertigo into four distinct syndromes:

• Acute vestibular syndrome: Continuous dizziness lasting days to weeks with nausea, vomiting, and intolerance to head motion (includes vestibular neuritis, labyrinthitis, posterior circulation stroke) 2
• Triggered episodic vestibular syndrome: Brief episodes (<1 minute) triggered by specific head/body position changes (includes BPPV, postural hypotension) 2
• Spontaneous episodic vestibular syndrome: Episodes lasting minutes to hours without triggers (includes vestibular migraine, Ménière's disease, vertebrobasilar TIA) 2
• Chronic vestibular syndrome: Dizziness lasting weeks to months (includes anxiety disorders, medication side effects, posterior fossa masses) 2

Critical Nystagmus Examination: The Primary Differentiator

Peripheral Vertigo Nystagmus Pattern:

• Horizontal with rotatory/torsional component 1
• Unidirectional (beats in same direction regardless of gaze) 1
• Suppressed by visual fixation 1
• Fatigable with repeated testing 1
• Brief latency period (few seconds) before onset 1

Central Vertigo Nystagmus Pattern (RED FLAGS):

• Pure vertical (upbeating or downbeating) without torsional component 2, 1, 3
• Direction-changing without changes in head position (periodic alternating nystagmus) 2, 1
• Direction-switching with gaze changes 1
• NOT suppressed by visual fixation 1, 4
• Baseline nystagmus present without provocative maneuvers 2, 1
• Persists without modification during repositioning maneuvers 1

Dix-Hallpike Maneuver Interpretation

Perform this maneuver to distinguish BPPV from central causes:

• Peripheral (BPPV): Characteristic nystagmus with latency (few seconds delay), fatigability on repeat testing, and torsional component 2, 1
• Central: Immediate onset, persistent nystagmus, purely vertical without torsional component 2, 1
• Downbeating nystagmus on Dix-Hallpike without torsional component is a critical red flag for central pathology 1

Associated Symptoms: Neurological Red Flags

Central vertigo frequently presents with additional neurological deficits that peripheral causes do not produce:

• Dysarthria, dysmetria, or dysphagia 1
• Sensory or motor deficits 1
• Diplopia 1
• Horner's syndrome 1
• New-onset severe headache (may indicate vertebrobasilar stroke or hemorrhage) 1

Common pitfall: Overlooking subtle neurological signs that indicate central pathology 1. Always perform a thorough cranial nerve and cerebellar examination.

Duration of Episodes: A Key Distinguishing Feature

• Vertebrobasilar insufficiency (central): Episodes typically last less than 30 minutes 2, 3
• Peripheral inner ear causes: Episodes typically last hours 3
• BPPV (peripheral): Episodes last less than 1 minute 2
• Ménière's disease (peripheral): Sustained vertigo attacks lasting hours with fluctuating hearing loss, aural fullness, and tinnitus 2

Special Clinical Scenarios Requiring Urgent Evaluation

Cerebellar Infarction: The Great Mimicker

Cerebellar infarction can masquerade as peripheral vestibular lesion because vertigo and severe imbalance may be the only presenting features. 3 MRI is indicated in any patient with acute vertigo and profound imbalance suspected to be cerebellar infarct or hemorrhage 3. Critical warning: 10% of cerebellar strokes present similarly to peripheral vestibular disorders 1.

Vertebrobasilar Insufficiency

• Isolated transient vertigo may precede stroke by weeks or months 2
• Attacks usually last less than 30 minutes without hearing loss 2
• Gaze-evoked nystagmus (typical of central lesions) 2
• Severe postural instability 2
• Nystagmus does not fatigue and is not suppressed by gaze fixation 2

Management Approach Based on Diagnosis

Peripheral Vertigo Management:

• BPPV: Canalith repositioning procedures (particle repositioning maneuver) 1
• Vestibular neuritis/labyrinthitis: Vestibular rehabilitation 1
• Response to treatment confirms peripheral diagnosis 1

Central Vertigo Management:

• Does NOT respond to canalith repositioning or vestibular rehabilitation 1
• Failure to respond to appropriate peripheral vertigo treatments is a red flag for central causes 1
• Requires neuroimaging (MRI preferred) and neurological consultation 4, 5

Common Pitfalls to Avoid

• Presence of syncope excludes peripheral causes of vertigo 5
• Elderly patients often have multifactorial vertigo requiring careful evaluation 5
• Do not miss medication-induced vertigo: Ototoxic medications (aminoglycosides), anticonvulsants, antihypertensives can cause vestibular symptoms 1
• Consider multiple concurrent vestibular disorders: BPPV can occur with Ménière's disease or vestibular neuritis 2
• Migraine-associated vertigo requires migraine symptoms (headache, photophobia, phonophobia, visual aura) during at least two vertiginous episodes to distinguish from BPPV 2