Residency · Residency · Neurology
Approach to the Dizzy Patient: Peripheral vs. Central Vertigo
Overview
"Dizziness" is one of the most common neurological complaints, but it is an imprecise term that can encompass vertigo, presyncope, disequilibrium, and non-specific lightheadedness. The critical clinical task is distinguishing benign peripheral vestibular disease from dangerous central causes such as posterior fossa stroke. A structured bedside approach using timing, triggers, and targeted examination can reliably make this differentiation without imaging in most cases.
Defining Dizziness Subtypes
Vertigo is the illusion of movement, usually spinning, and indicates vestibular pathology that may be either peripheral or central. Presyncope is the feeling of impending faint and suggests a cardiovascular cause such as orthostatic hypotension or arrhythmia. Disequilibrium refers to imbalance while walking and may indicate a gait disorder, neuropathy, or cerebellar dysfunction. Non-specific lightheadedness is vague and often multifactorial, with anxiety, hyperventilation, and medication effects among the common contributors. Patients often use these terms imprecisely, so the clinician should focus on the description of the experience rather than the label the patient applies to it.
TiTrATE Approach to Dizziness
A structured approach to the dizzy patient follows the TiTrATE framework: Timing (whether episodes are episodic or continuous, and how long they last), Triggers (positional, spontaneous, orthostatic, or situational), Associated symptoms and signs, and Targeted Examination based on the preceding information.
Timing and Trigger Framework
| Timing | Trigger | Likely Category | Examples |
|---|---|---|---|
| Seconds | Positional | Triggered episodic | BPPV |
| Minutes to hours | Spontaneous | Spontaneous episodic | Meniere disease, vestibular migraine |
| Days | Spontaneous | Acute prolonged | Vestibular neuritis, posterior fossa stroke |
| Chronic | Various | Chronic vestibular | PPPD, bilateral vestibulopathy |
Peripheral vs. Central Vertigo
Peripheral Vestibular Causes
The most common peripheral causes include benign paroxysmal positional vertigo (BPPV, the most common cause of vertigo overall), vestibular neuritis and labyrinthitis, Meniere disease, superior canal dehiscence syndrome, perilymphatic fistula, and complications of otitis media.
Central Vestibular Causes
Central causes include posterior fossa stroke (cerebellar or brainstem), multiple sclerosis with brainstem demyelination, posterior fossa tumors (vestibular schwannoma, cerebellopontine angle masses), vertebrobasilar insufficiency, Chiari malformation, and medication or toxin effects (anticonvulsants, aminoglycosides).
Distinguishing Features
| Feature | Peripheral | Central |
|---|---|---|
| Onset | Often sudden | Variable |
| Nystagmus | Unidirectional, horizontal-torsional | Direction-changing, vertical, or pure torsional |
| Nystagmus suppression | Suppressed by visual fixation | NOT suppressed by fixation |
| Hearing loss | May be present | Usually absent |
| Neurological signs | Absent | Present (diplopia, dysarthria, dysphagia, weakness, ataxia) |
| Imbalance | Mild-moderate, can walk | Severe, often cannot walk |
| Head impulse test | Positive (corrective saccade) | Negative (normal VOR) |
The HINTS Examination
When to Use HINTS
The HINTS examination is specifically designed for the acute vestibular syndrome (AVS), which is defined as acute onset of continuous vertigo with nystagmus, nausea and vomiting, and head-motion intolerance lasting more than 24 hours. In this context, HINTS distinguishes vestibular neuritis from posterior fossa stroke. It should not be used for episodic vertigo or in asymptomatic patients.
HINTS Components
HI -- Head Impulse Test
The head impulse test evaluates the vestibulo-ocular reflex (VOR). The patient fixates on the examiner's nose while the examiner performs rapid lateral head turns. A positive (abnormal) result is a corrective saccade after the head is turned toward the affected side. In peripheral vestibular disease, the head impulse test is positive, meaning the VOR is impaired on the affected side -- this is actually reassuring. In central pathology, the head impulse test is negative, meaning the VOR is normal bilaterally -- this is concerning. A normal head impulse test in a patient with acute vertigo and nystagmus is a red flag for stroke.
N -- Nystagmus
In peripheral vestibular disease, nystagmus is direction-fixed and horizontal-torsional, with the fast phase beating away from the affected ear, and it suppresses with visual fixation. Central red flags include direction-changing gaze-evoked nystagmus (which changes direction depending on the direction of gaze), vertical nystagmus (either up-beating or down-beating), pure torsional nystagmus, and nystagmus that does not suppress with visual fixation (best tested with Frenzel goggles or by observing the optic disc through an ophthalmoscope).
TS -- Test of Skew
The test of skew is performed as an alternate cover test. The examiner looks for a vertical corrective movement when each eye is uncovered. Skew deviation, a vertical ocular misalignment, suggests a central brainstem lesion. Peripheral vestibular lesions do not cause skew deviation.
HINTS Interpretation
HINTS is interpreted as central if any one of the following is present: a normal (negative) head impulse test, direction-changing nystagmus, or a positive test of skew (skew deviation). Any central HINTS finding means stroke until proven otherwise. Remarkably, HINTS has been shown to be more sensitive than initial MRI with diffusion-weighted imaging in the first 24 to 48 hours for detecting posterior fossa stroke, with a sensitivity of approximately 97% compared to about 83% for early MRI. HINTS is peripheral (reassuring for vestibular neuritis) when all three components are reassuring: an abnormal (positive) head impulse test, direction-fixed nystagmus, and no skew deviation.
Benign Paroxysmal Positional Vertigo (BPPV)
Pathophysiology
BPPV occurs when free-floating otoconia (calcium carbonate crystals) from the utricle migrate into a semicircular canal, where their movement creates inappropriate endolymph flow and a false sense of rotation. The posterior canal is affected in 85 to 90% of cases. Horizontal (lateral) canal BPPV is less common but important to recognize because it requires different diagnostic and treatment maneuvers.
Dix-Hallpike Test (Posterior Canal BPPV)
The Dix-Hallpike test is performed with the patient sitting, head turned 45 degrees to one side, and then rapidly lowered to a supine position with the head hanging about 20 degrees below the table edge. A positive result consists of upbeat-torsional nystagmus (with the torsional component beating toward the lower ear) appearing after a latency of 1 to 5 seconds, lasting less than 60 seconds, and fatiguing with repetition. Central positional nystagmus, by contrast, has no latency, does not fatigue, and is often purely vertical or direction-changing.
Epley Maneuver (Canalith Repositioning)
The Epley maneuver treats posterior canal BPPV through a series of head position changes that guide the displaced otoconia out of the posterior canal and back into the utricle. It is approximately 80% effective after a single treatment, though repetition may be needed. Post-maneuver restrictions such as sleeping upright or avoiding certain head positions are not supported by evidence.
Horizontal Canal BPPV
Horizontal canal BPPV is diagnosed with the supine roll test, in which the patient turns their head to each side while lying supine. Geotropic nystagmus (beating toward the ground on both sides, stronger on the affected side) indicates canalolithiasis. Apogeotropic nystagmus (beating away from the ground, stronger on the unaffected side) indicates cupulolithiasis. Treatment options include the Lempert (BBQ roll) maneuver or the Gufoni maneuver.
Vestibular Neuritis
Vestibular neuritis represents acute unilateral vestibular loss, usually viral or post-viral in origin. It presents with continuous vertigo lasting days, accompanied by severe nausea and vomiting. There is no hearing loss; when hearing loss accompanies the syndrome, labyrinthitis should be considered. The HINTS examination shows an abnormal (positive) head impulse test, direction-fixed nystagmus beating away from the affected ear, and no skew deviation. Treatment involves short-term vestibular suppressants (meclizine, diazepam) and antiemetics, with early vestibular rehabilitation being crucial for recovery. Corticosteroids such as methylprednisolone may improve recovery, though the evidence is modest. Most patients improve over weeks, though some develop chronic dizziness or BPPV.
Meniere Disease
Meniere disease presents with episodes of vertigo lasting 20 minutes to 12 hours, accompanied by fluctuating sensorineural hearing loss, tinnitus, and aural fullness. The audiogram characteristically shows low-frequency hearing loss. The underlying pathophysiology is endolymphatic hydrops. Treatment includes dietary sodium restriction, diuretics (with limited evidence), intratympanic dexamethasone, intratympanic gentamicin for chemical labyrinthectomy, and surgical options for refractory cases.
Vestibular Migraine
Vestibular migraine is the most common cause of episodic spontaneous vertigo. Episodes last from 5 minutes to 72 hours and are accompanied by migraine features such as headache, photophobia, or visual aura, though headache may be absent during vestibular episodes. Diagnosis follows the ICHD-3/Barany Society criteria. Treatment centers on migraine prophylaxis with agents such as topiramate, beta-blockers, amitriptyline, or CGRP antibodies.
When to Image Urgently
Urgent neuroimaging is indicated for an acute vestibular syndrome with any HINTS central sign, new vertigo accompanied by focal neurological deficits, acute onset worst-ever vertigo, vertigo with severe headache or neck pain (raising concern for dissection), patients with significant stroke risk factors (age over 60, hypertension, diabetes, atrial fibrillation), and progressive unilateral hearing loss (raising concern for a cerebellopontine angle mass).
<image>A step-by-step illustrated guide to the HINTS examination with three panels. Panel 1 (Head Impulse Test): shows examiner holding patient's head and performing rapid lateral head thrust, with inset showing a corrective saccade eye movement trace for a positive (peripheral) result. Panel 2 (Nystagmus assessment): shows direction-fixed horizontal nystagmus in peripheral vertigo versus direction-changing gaze-evoked nystagmus in central vertigo, with eye position diagrams for each gaze direction. Panel 3 (Test of Skew): shows alternate cover test technique with vertical refixation movement in a positive (central) result. A flowchart at the bottom summarizes: all peripheral = vestibular neuritis; any central feature = stroke until proven otherwise.</image>
<image>An illustrated guide to the Dix-Hallpike test and Epley maneuver. The top row shows the Dix-Hallpike test: patient sitting with head turned 45 degrees to the right, then rapidly brought to supine with head hanging, with inset showing the expected upbeat-torsional nystagmus pattern and a diagram of otoconia moving in the posterior semicircular canal. The bottom row shows the sequential positions of the Epley canalith repositioning maneuver (5 positions) with arrows indicating otoconia movement through and out of the posterior canal at each step. The semicircular canal anatomy is shown in cross-section at each position.</image>
<image>A comparative diagnostic table illustrated as an infographic showing the key differentiating features of BPPV, vestibular neuritis, Meniere disease, vestibular migraine, and posterior fossa stroke. Each condition has an icon and lists: typical duration, key triggers, associated symptoms, nystagmus pattern, hearing involvement, and recommended evaluation. Color-coded risk levels (green for benign, yellow for moderate concern, red for emergency) are used for visual triage guidance.</image>
Clinical Pearls
A normal head impulse test in the setting of acute vertigo and nystagmus is a red flag for central pathology because the VOR should be impaired in peripheral vestibular neuritis. HINTS is more sensitive than early MRI-DWI for detecting posterior fossa stroke in the first 24 to 48 hours. BPPV is the most common cause of vertigo, produces brief episodes lasting seconds, is triggered by position changes, and is diagnosed at the bedside with the Dix-Hallpike test -- imaging is not required. HINTS should never be used in episodic vertigo or when the patient is asymptomatic, as it is validated only for the acute vestibular syndrome. Vertical nystagmus, whether up-beating or down-beating, is almost always central in origin. Vestibular migraine is the most common cause of spontaneous episodic vertigo and does not require headache to be present during the episode. Posterior canal BPPV nystagmus has a latency of 1 to 5 seconds, is brief (under 60 seconds), and fatigues with repetition; absence of these features suggests central positional nystagmus. Gait should always be assessed in dizzy patients -- inability to walk is concerning for a central lesion even if other HINTS components appear peripheral.
References
- Kattah JC, et al. HINTS to diagnose stroke in the acute vestibular syndrome. Stroke. 2009;40(11):3504-3510.
- Newman-Toker DE, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and nystagmus. Acad Emerg Med. 2013;20(10):986-996.
- Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;(12):CD003162.
- Lempert T, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012;22(4):167-172.
