What finding is most consistent with a peripheral cause of vertigo in a patient with sudden-onset dizziness worsening with head movement?

Tinnitus is Most Consistent with Peripheral Vertigo

Tinnitus is the finding most consistent with a peripheral cause of vertigo in this patient. Peripheral vestibular disorders commonly present with auditory symptoms including tinnitus, hearing loss, and aural fullness, which are absent in central causes 1.

Key Distinguishing Features

Peripheral Vertigo Characteristics

• Auditory symptoms are hallmark features of peripheral vestibular pathology, including tinnitus, fluctuating hearing loss, and aural fullness 1
• The most common peripheral causes in this clinical scenario include vestibular neuritis, labyrinthitis, benign paroxysmal positional vertigo (BPPV), and Ménière's disease 1
• Peripheral vertigo typically presents with severe rotational vertigo that worsens with head movement, consistent with this patient's presentation 2, 3

Central Vertigo Red Flags (What This Patient Does NOT Have)

• Difficulty swallowing (dysphagia) suggests brainstem involvement and indicates a central cause 4
• Diplopia indicates cranial nerve involvement or brainstem pathology, pointing to a central lesion 4
• Vertical nystagmus (particularly downbeat or upbeat) is nearly always indicative of a central cause, specifically cerebellar or brainstem pathology 1, 4

Clinical Reasoning Algorithm

Step 1: Assess Nystagmus Pattern

• Horizontal or horizontal-rotatory nystagmus → suggests peripheral cause 1
• Pure vertical nystagmus → strongly suggests central cause 1
• Direction-changing nystagmus without head position change → central cause 1

Step 2: Evaluate for Neurologic Deficits

• Presence of cranial nerve deficits (diplopia, dysphagia, dysarthria) → central cause requiring urgent neuroimaging 1
• Isolated vertigo without focal neurologic signs → likely peripheral, though 11-25% may still have posterior circulation stroke 1

Step 3: Check for Auditory Symptoms

• Tinnitus, hearing loss, or aural fullness present → strongly favors peripheral cause 1
• No auditory symptoms → does not exclude peripheral cause but raises concern for central pathology if other red flags present 1

Critical Pitfall to Avoid

Do not assume normal neurologic examination excludes stroke. Up to 75-80% of patients with acute vestibular syndrome from posterior circulation infarction may lack focal neurologic deficits 1. However, the presence of tinnitus in this case strongly suggests a peripheral etiology, as auditory symptoms are not features of central causes 1, 4.

When to Image Despite Peripheral Features

• Age >50 years with vascular risk factors 1
• Severe imbalance out of proportion to vertigo (suggests cerebellar involvement) 4
• HINTS examination suggesting central cause (absent head impulse test, direction-changing nystagmus, vertical skew deviation) 1