Central Vertigo: Falling When Walking is the Most Concerning Feature
Among the options presented, falling when walking is the most concerning feature for central vertigo, as it indicates severe postural instability and truncal ataxia—hallmark signs of cerebellar or brainstem pathology that distinguish central from peripheral causes.
Key Distinguishing Features
Postural Instability and Gait Disturbance
Severe postural instability with falling is a primary distinguishing feature of central vertigo, particularly vertebrobasilar insufficiency and cerebellar lesions, according to the American Academy of Otolaryngology-Head and Neck Surgery 1
Truncal ataxia with inability to maintain balance while walking is indicative of lower cerebellar lesions, which may present without other obvious neurological signs 2
Central causes produce significantly more severe balance impairment compared to peripheral vestibular disorders, where patients can typically maintain some degree of postural control 1
Why Other Options Are Less Concerning for Central Vertigo
Recurrent episodes lasting minutes to hours:
- This pattern is actually characteristic of peripheral causes like Ménière's disease (hours-long episodes) or vertebrobasilar TIA (minutes), making it non-specific 3
- Both peripheral and central causes can present with this temporal pattern 1
Tinnitus in the right ear:
- Tinnitus is a peripheral vestibular symptom associated with Ménière's disease, labyrinthitis, and posttraumatic vertigo 1, 3
- Central lesions typically do not produce tinnitus unless they affect the auditory pathways directly 4
Unidirectional, horizontal nystagmus:
- This is the classic pattern of peripheral vertigo, particularly in vestibular neuritis and BPPV 3
- Central vertigo typically produces gaze-evoked nystagmus (direction-changing with gaze), pure vertical nystagmus, or nystagmus that is not suppressed by visual fixation 1, 3
Critical Red Flags for Central Vertigo
Nystagmus Patterns That Suggest Central Pathology
- Pure vertical nystagmus (upbeating or downbeating) without torsional component 3
- Direction-changing nystagmus without changes in head position 3
- Nystagmus that does not fatigue with repeated testing and is not suppressed by gaze fixation 1
- Gaze-evoked nystagmus typical of central lesions 1
Associated Neurological Signs
Additional neurological deficits such as dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, or Horner's syndrome strongly suggest central pathology 3
The presence of cerebellar ocular motor abnormalities alongside positional nystagmus indicates a central lesion 5
Clinical Pitfall to Avoid
Do not dismiss severe gait instability as simply "dizziness"—this patient's falling to the side with off-balance sensation represents truncal ataxia, which is a neurological emergency requiring urgent imaging to rule out posterior circulation stroke or cerebellar lesion 1, 3, 4. The combination of vertigo with severe postural instability warrants immediate neuroimaging, as isolated transient vertigo may precede vertebrobasilar stroke by weeks or months 1, 3.