Dizziness and Vertigo

Last Updated on by FRCEM Intermediate

Peripheral vertigo is caused by disturbance of the vestibular system in the inner ear

Common causes of peripheral vertigo include:

  • Benign paroxysmal positional vertigo
  • Vestibular neuritis
  • Labyrinthitis
  • Meniere’s disease

Central vertigo is caused by a disturbance to the visual-vestibular interaction centers in the brainstem and cerebellum, or to sensory pathways to and from the thalamus

Common causes of central vertigo:

  • Migraine (most common cause)
  • Stroke
  • TIA
  • Cerebellar tumour
  • Acoustic neuroma
  • Multiple sclerosis

Symptoms suggest central vertigo

  • Signs and symptoms do not match any of the features of peripheral causes of vertigo
  • Persistent, severe or prolonged vertigo
  • New-onset headache
  • Focal neurological signs and symptoms
  • Central-type nystagmus
  • Abnormal response to the Hallpike manoeuvre
  • Prolonged, severe imbalance
  • No other ENT symptoms such as hearing loss, tinnitus or aural fullness
  • Head impulse test is negative
  • Onset of symptoms is hyperacute within a few seconds.
  • The vertigo is central in character i.e.
    • unaffected by head position
    • little systemic upset
    • generally there are co-existing neurological deficits e.g. ataxia, depressed level of consciousness. Rarely, vertigo may be the only finding.


  • Nystagmus is also typically central;
    • Horizontal, rotatory or vertical
    • Bidirectional
    • Not suppressed by visual fixation



HINTS+ exam

Nystagmus None/
Test of skew NO vertical skew Vertical
Head Impulse Test Abnormal Normal
+ Bedside test of hearing NO new loss New loss


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