From the Guidelines
Peripheral vertigo and central vertigo are two distinct types of dizziness that differ in their origin, symptoms, and treatment approaches, with peripheral vertigo typically presenting with intense, spinning sensations and central vertigo presenting with milder, more constant dizziness and associated neurological symptoms.
Key Differences
- Peripheral vertigo originates from problems in the inner ear balance system, while central vertigo stems from issues in the brain, particularly the brainstem and cerebellum.
- Peripheral vertigo is typically more severe but self-limiting with prominent ear symptoms, while central vertigo is often milder but persistent with associated neurological symptoms.
Causes and Treatment
- Common causes of peripheral vertigo include benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Ménière's disease, and labyrinthitis.
- Treatment for peripheral vertigo includes repositioning maneuvers like the Epley maneuver for BPPV, medications such as meclizine (25-50mg every 4-6 hours), diazepam (2-5mg as needed), or promethazine (12.5-25mg every 4-6 hours) for symptom management, and vestibular rehabilitation exercises.
- Central vertigo is typically caused by stroke, multiple sclerosis, tumors, or migraine, and requires prompt medical attention as it may indicate serious neurological conditions.
Diagnosis
- Diagnosis involves a careful history, physical examination including the Dix-Hallpike test for BPPV, and sometimes imaging studies like MRI for suspected central causes, as recommended by the most recent guidelines 1.
- The HINTS examination has been shown to be a useful tool in distinguishing between peripheral and central vertigo, with a high sensitivity for detecting central causes when performed by specially trained practitioners 1.
Recent Guidelines
- The American College of Radiology recommends that patients with acute vestibular syndrome (AVS) and a normal neurologic examination may not require imaging if the HINTS examination is negative, but imaging may be required to rule out stroke 1.
- The guidelines also emphasize the importance of a careful history and physical examination in diagnosing and managing vertigo, and recommend the use of vestibular rehabilitation exercises and other conservative management strategies for peripheral vertigo 2, 3.
From the Research
Peripheral vs Central Vertigo
The distinction between peripheral and central vertigo is crucial for accurate diagnosis and treatment.
- Peripheral vertigo is often caused by benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuronitis, among other conditions 4, 5.
- Central vertigo, on the other hand, can be a symptom of more serious conditions such as cerebrovascular disease, multiple sclerosis, and intracranial neoplasms 4, 6.
Clinical Presentations
The clinical presentation of vertigo can aid in differentiating between peripheral and central causes.
- Peripheral vertigo typically presents with symptoms such as rotational vertigo, nausea, and vomiting, often triggered by specific head movements or positions 5, 7.
- Central vertigo, by contrast, may present with additional neurologic signs and symptoms, such as nystagmus that does not lessen with focus, indicating a more serious underlying condition 4, 6.
Diagnostic Approach
A systematic approach to diagnosing vertigo involves categorizing the patient's symptoms and performing a thorough physical examination, including special tests such as the Dix-Hallpike maneuver 4, 5.
- The tempo of vertiginous attacks and associated symptoms can help differentiate between various causes of peripheral vertigo, including benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuronitis 5, 7.
- Further work-up with laboratory and radiologic studies, such as magnetic resonance imaging, may be necessary to confirm a central cause of vertigo 4, 6.
Treatment Options
Treatment options for vertigo depend on the underlying cause and may include vestibular rehabilitation, medication, and surgery.
- Vestibular rehabilitation has been shown to be effective in improving symptoms and quality of life for patients with peripheral vertigo, particularly those with benign paroxysmal positional vertigo and vestibular neuritis 7, 8.
- The efficacy of vestibular rehabilitation can be influenced by factors such as headache and severe vertigo disorder before intervention 7.