What is the treatment for central vertigo?

Treatment of Central Vertigo

Central vertigo requires urgent identification of the underlying neurological cause and treatment directed at that specific etiology—stroke, tumor, multiple sclerosis, or other CNS pathology—rather than symptomatic vestibular suppressant medications, which are ineffective for central causes and may mask dangerous neurological deterioration. 1

Immediate Diagnostic Imperative

Central vertigo represents a neurological emergency requiring rapid differentiation from benign peripheral causes. The priority is identifying life-threatening conditions such as brainstem or cerebellar stroke, which account for serious morbidity and mortality. 1

Key Clinical Features Indicating Central Vertigo

Look for these specific examination findings that distinguish central from peripheral causes:

• Nystagmus patterns: Downbeating nystagmus on Dix-Hallpike (especially without torsional component), direction-changing nystagmus without head position changes (periodic alternating nystagmus), gaze-evoked nystagmus, or direction-switching nystagmus (beats right with right gaze, left with left gaze) 1
• Associated neurological deficits: Dysarthria, dysmetria, dysphagia, sensory or motor loss, Horner's syndrome, gait ataxia, speech dysfunction, or autonomic dysfunction 1, 2
• Baseline nystagmus without provocative maneuvers (though this could also indicate vestibular neuritis) 1

Critical Pitfall

Approximately 10% of cerebellar strokes present similarly to peripheral vestibular processes without obvious neurological signs initially, making vigilance essential. 1

Treatment Algorithm for Central Vertigo

Step 1: Identify the Specific Central Cause

Central vertigo is not a diagnosis—it is a symptom of underlying CNS pathology. Treatment depends entirely on the etiology:

Brainstem or Cerebellar Stroke/TIA

• Immediate neuroimaging (MRI preferred over CT for posterior fossa) 1
• Acute stroke protocols: Thrombolysis or thrombectomy if within appropriate time windows 1
• Secondary stroke prevention: Antiplatelet therapy, anticoagulation if cardioembolic, risk factor modification 1
• Rehabilitation: Physical therapy and vestibular rehabilitation once stable 3

Vestibular Migraine

This accounts for 11.4% of vertigo cases and requires specific diagnostic criteria: ≥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), and other causes ruled out. 1, 3

• Acute treatment: Triptans or NSAIDs for acute episodes 4
• Prophylaxis: Tricyclic antidepressants, beta blockers, or calcium channel blockers 4
• Dietary modifications: Identify and avoid migraine triggers 4

Multiple Sclerosis or Other Demyelinating Disease

• Disease-modifying therapy as per neurology consultation 1
• Symptomatic management during acute exacerbations 1

Intracranial Tumors

• Neurosurgical evaluation for resection or biopsy 1
• Radiation or chemotherapy as indicated 1

Cerebellar Ataxia Syndromes

• Aminopyridine, chlorzoxazone, or acetyl-DL-leucine for various cerebellar diseases 3
• Supportive care and rehabilitation 3

Step 2: Avoid Inappropriate Vestibular Suppressants

Vestibular suppressant medications (meclizine, prochlorperazine, benzodiazepines) are not recommended for central vertigo. 5, 6, 7 These medications:

• Do not address the underlying CNS pathology 5, 6
• May mask evolving neurological deterioration 1
• Cause drowsiness and cognitive deficits that interfere with neurological assessment 5, 6, 7
• Increase fall risk, especially in elderly patients 5, 6, 7
• Can decrease diagnostic sensitivity during examination 6

Step 3: Limited Role for Symptomatic Management

Only for severe nausea/vomiting: Short-term prochlorperazine (5-10 mg, maximum three doses per 24 hours) may be used temporarily while definitive treatment is initiated. 6, 7 This is purely for autonomic symptoms, not for treating the vertigo itself.

Step 4: Vestibular Rehabilitation

Once the acute central cause is stabilized and treated, vestibular rehabilitation exercises can help with residual balance dysfunction and promote central compensation. 3 This is particularly important for patients with permanent vestibular deficits from stroke or other irreversible CNS damage.

When to Suspect Central Rather Than Peripheral Vertigo

Failure to respond to conservative management (such as canalith repositioning procedures or vestibular rehabilitation) should raise immediate concern that the underlying diagnosis is central, not peripheral. 1

In one study, CNS disorders explained 3% of apparent BPPV treatment failures, emphasizing the importance of reassessment when symptoms persist. 1

Follow-Up Requirements

Reassess within 1 month after initial treatment to document resolution or persistence of symptoms, and adjust treatment based on the specific central etiology and response to therapy. 5, 7 For stroke patients, this includes monitoring for recurrent events and optimizing secondary prevention strategies.