Does persistent vertigo in an older patient with vascular risk factors or a history of head trauma suggest a central nervous system cause?

Persistent Vertigo and Central Origin: Clinical Assessment

Persistent vertigo alone does NOT reliably indicate a central cause—most persistent vertigo is peripheral (vestibular neuritis), but the presence of vascular risk factors, head trauma history, or neurologic findings significantly increases the likelihood of central pathology requiring urgent imaging. 1, 2, 3

Understanding Persistent vs. Brief Vertigo

The duration pattern matters more than persistence alone for determining central vs. peripheral origin:

• Acute persistent vertigo (days to weeks of constant symptoms) is most commonly peripheral in origin, typically vestibular neuritis (41% of peripheral vertigo cases) or labyrinthitis 1, 2
• However, posterior circulation stroke accounts for 25% of acute vestibular syndrome presentations, rising to 75% in high vascular risk cohorts 1
• Brief episodic vertigo (seconds to minutes) triggered by position changes suggests BPPV (42% of all vertigo cases), which is peripheral 1, 2

Critical Red Flags Suggesting Central Origin

In older patients with vascular risk factors or head trauma, the following mandate urgent MRI brain without contrast: 1, 3

• Focal neurological deficits (diplopia, dysarthria, dysphagia, limb weakness, sensory changes) 1, 2, 3
• Abnormal HINTS examination findings: normal head impulse test, direction-changing or vertical nystagmus, or skew deviation present 1, 2, 3
• Inability to stand or walk (severe imbalance out of proportion to vertigo suggests cerebellar involvement) 1, 2
• Downbeating or pure vertical nystagmus (strongly suggests central pathology) 1, 2
• Sudden unilateral hearing loss 1
• New severe headache accompanying vertigo 1

The Dangerous Misconception About Normal Neurologic Exams

A normal neurologic examination does NOT exclude stroke—this is a critical pitfall. Up to 75-80% of patients with posterior circulation infarction causing acute vestibular syndrome have NO focal neurologic deficits on standard examination. 2, 3 In one study, 11% of patients with acute persistent vertigo and no focal neurologic symptoms had acute infarct on imaging. 3

High-Risk Populations Requiring Lower Threshold for Imaging

Obtain MRI brain without contrast even with normal neurologic exam if: 1, 2

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke) 1
• History of head trauma (treatment failure after BPPV maneuvers was most common in head trauma patients due to widespread vestibular dysfunction) 4
• High vascular risk patients with acute vestibular syndrome (11-25% may have posterior circulation stroke despite normal exam) 1, 3

When Persistent Vertigo is Likely Peripheral

Persistent vertigo is more likely peripheral when: 1, 2

• Auditory symptoms present: tinnitus, fluctuating hearing loss, or aural fullness strongly favor peripheral causes (Ménière's disease, labyrinthitis) 1, 2
• Horizontal or horizontal-rotatory nystagmus that lessens with visual fixation 2, 5
• Positive Dix-Hallpike test with characteristic findings (5-20 second latency, torsional upbeating nystagmus, resolution within 60 seconds) 1
• Normal HINTS examination performed by trained examiner (abnormal head impulse test, unidirectional horizontal nystagmus, no skew deviation) 1, 3

Treatment Failure as a Red Flag

Persistent symptoms after appropriate treatment increase the likelihood of central pathology: 4

• CNS disorders masquerading as BPPV were found in 3% of treatment failures 4
• Reassessment should include examination for other semicircular canal involvement, coexisting vestibular dysfunction, or central causes 4
• In 12-20% of cases, positional vertigo may be attributed to CNS pathology including cerebellar tumors 6

Practical Algorithm for Persistent Vertigo in High-Risk Patients

Step 1: Determine if vertigo is truly persistent (days-weeks) vs. episodic 1

Step 2: Assess for red flags (focal deficits, severe imbalance, abnormal nystagmus patterns, sudden hearing loss, severe headache) 1, 2, 3

Step 3: If red flags present OR high vascular risk (age >50, hypertension, diabetes, prior stroke) OR head trauma history → obtain MRI brain without contrast immediately 1, 2

Step 4: If no red flags and low vascular risk, perform HINTS examination (if trained) or refer for specialized vestibular assessment 1, 3

Step 5: If peripheral features confirmed and BPPV suspected, perform Dix-Hallpike and treat with Epley maneuver 1

Step 6: If symptoms persist after appropriate peripheral treatment, reassess for central causes 4

Common Pitfalls to Avoid

• Do not assume normal neurologic exam excludes stroke in older patients with vascular risk factors 2, 3
• Do not rely on CT head for isolated vertigo (diagnostic yield <1%, misses most posterior circulation infarcts) 1
• Do not dismiss persistent vertigo after head trauma as purely peripheral without considering central causes 4
• Do not overlook atypical nystagmus patterns (vertical, direction-changing, or persistent without positional trigger) as indicators of central pathology 1, 2, 6, 7