From the Guidelines
Central vertigo can be differentiated from peripheral vertigo by identifying key clinical features, such as atypical nystagmus patterns, failure to respond to conservative management, and associated neurologic symptoms.
Key Differentiating Features
- Nystagmus findings: downbeating nystagmus on the Dix-Hallpike maneuver, direction-changing nystagmus, gaze holding, direction-switching nystagmus, and baseline nystagmus without provocative maneuvers are more suggestive of a central cause of vertigo 1.
- Associated neurologic symptoms: symptoms such as dysarthria, dysmetria, dysphagia, sensory or motor loss, or findings of Horner’s syndrome are indicative of a central cause of vertigo 1.
- Failure to respond to conservative management: failure to respond to canalith repositioning procedures (CRP) or vestibular rehabilitation (VR) should raise concern for a central cause of vertigo 1.
- Vestibular migraine: can be distinguished from BPPV by the presence of migrainous symptoms, such as headache, photophobia, phonophobia, and visual aura 1, 2.
Diagnostic Approach
- Clinical evaluation: a thorough clinical evaluation, including a detailed history and physical examination, is essential to differentiate between central and peripheral vertigo 1, 2.
- Imaging: imaging studies, such as MRI, may be necessary in patients with atypical features or failure to respond to conservative management 2, 3.
- HINTS examination: the HINTS examination, which includes the head impulse, nystagmus, and test of skew, can help differentiate between central and peripheral vertigo 4, 5.
Important Considerations
- Central causes of vertigo: include vestibular migraine, brainstem and cerebellar stroke or transient ischemic attacks, and intracranial tumors or disorders, such as multiple sclerosis 1.
- Peripheral causes of vertigo: include benign paroxysmal positional vertigo (BPPV), vestibular neuritis, and Menière disease 2, 4.
From the Research
Differentiating Central and Peripheral Vertigo
To differentiate between central and peripheral vertigo, several factors can be considered:
- The history of the patient, which usually provides key information for distinguishing between peripheral and central causes of vertigo 6
- The duration of attacks, with vertigo associated with vertebrobasilar insufficiency typically lasting minutes, whereas peripheral inner ear causes of recurrent vertigo typically lasting hours 6
- The presence of positional vertigo, which nearly always is a benign condition but can be a symptom of a central lesion in rare cases 6
- The type of nystagmus, with central positional nystagmus nearly always being purely vertical (either upbeating or downbeating) and usually associated with neurologic findings 6
Diagnostic Approaches
Diagnostic approaches for differentiating between central and peripheral vertigo include:
- Assessing nystagmus patterns 7
- Evaluating the vestibulo-ocular reflex 7
- Using the HINTS Plus test 7
- Imaging studies, such as MRI, which can help identify central causes when clinical findings are inconclusive 6, 7
- Audiological testing and neuroimaging to provide further information to guide patient management 8
Clinical Evaluation
A careful history and physical examination can distinguish between central and peripheral causes of vertigo 9, 8. The clinical assessment aims to:
- Establish the presence of true vertigo
- Differentiate between vertigo of central or peripheral origins
- Evaluate the need for urgent investigations and referrals 8
- Consider the presence of syncope, which excludes peripheral causes of vertigo 8
- Evaluate the patient's age, as vertigo in the elderly population is likely to be multifactorial and warrants careful evaluation 8