From the Guidelines
Central causes of dizziness should be suspected in patients presenting with acute persistent vertigo, particularly if they have risk factors for cerebrovascular disease, and a thorough evaluation including the HINTS examination and potentially neuroimaging should be considered to rule out posterior circulation infarct. The HINTS examination, which includes assessment of horizontal nystagmus, head impulse test, and test of skew, can be highly sensitive for detecting central causes of vertigo when performed by specially trained practitioners 1. Patients with central causes of dizziness may present with additional neurological symptoms such as double vision, slurred speech, facial numbness, or coordination problems, although up to 75% of patients with posterior circulation infarct may not have associated focal neurologic deficits 1.
Key central causes of dizziness include:
- Stroke or transient ischemic attack (TIA), particularly in the cerebellum or brainstem
- Vestibular migraine, which can be diagnosed based on clinical criteria and may respond to migraine prophylaxis medications
- Multiple sclerosis, which can damage nerve pathways involved in balance
- Brain tumors that compress structures involved in equilibrium
- Neurodegenerative disorders like Parkinson's disease
- Medications that affect the central nervous system, such as anticonvulsants, antidepressants, and sedatives
Diagnosis of central causes of dizziness typically requires a combination of clinical evaluation, including the HINTS examination, and neuroimaging such as MRI, especially in patients with risk factors for cerebrovascular disease or those with abnormal findings on the HINTS examination 1. Treatment should focus on addressing the underlying condition, such as urgent medical intervention for stroke, rather than just symptom management.
From the Research
Central Causes of Dizziness
The central causes of dizziness are a significant concern due to their potential urgency and impact on patient health. According to 2, central nervous system disorders must be excluded when diagnosing dizziness, and central causes are responsible for almost one-fourth of the dizziness experienced by patients.
Common Central Causes
Some of the most common central causes of dizziness and vertigo include:
- Cerebrovascular disorders related to the vertebrobasilar circulation
- Migraine
- Multiple sclerosis
- Tumors of the posterior fossa
- Neurodegenerative disorders
- Certain drugs
- Psychiatric disorders 2
Diagnosis and Evaluation
Diagnosing central causes of dizziness can be challenging, but a thorough patient history, neurologic examination, and imaging studies are usually key to differentiating between peripheral and central causes of vertigo 2. The HINTS (head-impulse, nystagmus, test of skew) examination can also help distinguish peripheral from central etiologies 3, 4.
Treatment and Management
Treatment for central causes of dizziness depends on the underlying etiology and may require urgent attention. Vestibular rehabilitation can be helpful in treating many peripheral and central etiologies 3, while other specific treatments may be necessary to address the cause of the dizziness. Pharmacologic intervention is limited due to its potential impact on the central nervous system's ability to compensate for dizziness 3.