Is vertigo a condition that falls under the realm of neurology?

Does Neurology Deal with Vertigo?

Yes, neurology absolutely deals with vertigo, particularly when it arises from central nervous system pathology, though vertigo evaluation requires distinguishing between peripheral (otologic) and central (neurologic) causes. 1

The Dual Nature of Vertigo Management

Vertigo is fundamentally a multidisciplinary symptom that falls under both neurology and otolaryngology depending on the underlying etiology. 2, 3

When Vertigo is Neurological (Central Causes)

Neurologists manage vertigo when it originates from CNS lesions, which include: 1

• Vertebrobasilar insufficiency/stroke - Isolated transient vertigo may precede stroke by weeks or months, with attacks typically lasting less than 30 minutes without hearing loss 1, 4
• Migraine-associated vertigo - Accounts for approximately 14% of vertigo cases and is predominantly central in nature 1
• Intracranial tumors including posterior fossa masses and vestibular schwannomas 1, 4
• Multiple sclerosis 3
• Cerebellar lesions 2

When Vertigo is Otologic (Peripheral Causes)

Otolaryngology primarily manages peripheral vestibular disorders: 1, 4

• Benign paroxysmal positional vertigo (BPPV) - The most common cause, accounting for 42% of cases 4
• Vestibular neuritis - Accounts for 41% of peripheral vertigo cases 4
• Ménière's disease - Characterized by fluctuating hearing loss, tinnitus, and aural fullness 1, 4
• Labyrinthitis 1, 4

Critical Neurological Red Flags Requiring Immediate Evaluation

Neurologists must urgently evaluate vertigo when these features are present: 4

• Severe postural instability with falling - Particularly suggests vertebrobasilar insufficiency or cerebellar pathology 1, 4
• Downbeating nystagmus on Dix-Hallpike without torsional component 1, 4
• Direction-changing nystagmus without head position changes 1
• Baseline nystagmus without provocative maneuvers 1, 4
• Nystagmus not suppressed by visual fixation 1, 4
• Any additional neurological symptoms including dysarthria, dysmetria, dysphagia, diplopia, limb weakness, or sensory deficits 4
• New-onset severe headache with vertigo suggesting vertebrobasilar stroke 4
• Gaze-evoked nystagmus typical of central lesions 1, 4

The Neurologist's Diagnostic Approach

The key clinical task is differentiating peripheral from central causes, as approximately 25% of patients with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts. 4

Nystagmus Examination Distinguishes Central from Peripheral

Central vertigo nystagmus characteristics: 4

• Pure vertical (upbeating or downbeating) without torsional component
• Direction-changing without head position changes
• Not suppressed by visual fixation
• Does not fatigue with repeated testing

Peripheral vertigo nystagmus characteristics: 4

• Horizontal with rotatory component
• Unidirectional
• Suppressed by visual fixation
• Fatigable with repeated testing
• Brief latency before onset

Common Pitfalls to Avoid

The most critical error is missing central causes that mimic peripheral disorders - approximately 10% of cerebellar strokes present similarly to peripheral vestibular disorders. 4

Failure to respond to peripheral vertigo treatments (canalith repositioning, vestibular rehabilitation) should immediately raise concern for central pathology. 1, 4

After headache, vertigo is the most frequent major complaint in neurology, making it essential that neurologists maintain expertise in vertigo evaluation. 5