03/03/2026
🧠 Clinical Approach to Vertigo
A Practical Guide for Clinicians
Vertigo is one of the most misdiagnosed neurological complaints.
The key is pattern recognition + focused examination.
🔹 Step 1: Confirm True Vertigo
Ask:
> “Do you feel the surroundings are spinning?”
✔️ Spinning sensation → True vertigo
❌ Lightheadedness → Think anemia, hypotension, hypoglycemia
📌 Not all dizziness is vertigo.
🔴 Step 2: Rule Out Central Causes First
Any of the following = Central until proven otherwise
Neurological deficit
Direction-changing or vertical nystagmus
Severe gait ataxia (cannot walk independently)
Sudden severe headache
Normal head impulse test in acute severe vertigo
Elderly with vascular risk factors
⚠️ CT can be normal in posterior circulation stroke → MRI required.
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🟢 Peripheral vs Central – Quick Comparison
🟢 Peripheral Vertigo
Acute, severe spinning
Worse with head movement
Prominent nausea & vomiting
Hearing symptoms may be present
Horizontal, unidirectional nystagmus
Abnormal head impulse test
🔴 Central Vertigo
Persistent or less intense
Not position-related
Neurological deficits present
Vertical or direction-changing nystagmus
Normal head impulse test
🎯 Common Peripheral Causes
1️⃣ Benign Paroxysmal Positional Vertigo (BPPV)
Seconds duration
Triggered by position
No hearing loss
Positive Dix–Hallpike
Normal between attacks
📌 Continuous vertigo ≠ BPPV
2️⃣ Vestibular neuritis
Acute severe vertigo lasting days
Post-viral
Hearing intact
Abnormal head impulse
📌 Vertigo + intact hearing → Neuritis
3️⃣ Labyrinthitis
Acute vertigo
Hearing loss present
Tinnitus
📌 Neuritis + hearing loss = Labyrinthitis
4️⃣ Ménière disease
Recurrent attacks (20 min–hours)
Fluctuating hearing loss
Tinnitus + ear fullness
📌 Classic triad = Vertigo + Hearing loss + Tinnitus
5️⃣ Vestibular schwannoma
(Acoustic neuroma)
Gradual onset
Progressive unilateral hearing loss
Chronic imbalance
Possible facial numbness
📌 Slowly progressive unilateral hearing loss → Rule out CPA tumor
🧠 Central Causes to Always Consider
Posterior circulation stroke (PICA / AICA)
Cerebellar infarction
Vertebrobasilar insufficiency
Multiple sclerosis
Brainstem tumors
Vestibular migraine
🔬 The HINTS Exam (Acute Vestibular Syndrome)
Head impulse
Nystagmus
Test of skew
📌 HINTS is more sensitive than CT for posterior stroke when performed correctly.
🚨 High-Yield Clinical Pearls
✔ Severe vomiting does NOT exclude central cause
✔ Continuous vertigo ≠ BPPV
✔ Hearing loss usually indicates peripheral origin
✔ Inability to walk independently = central until proven otherwise
✔ Direction-changing nystagmus = CNS pathology
✔ Sudden vertigo + worst headache of life = rule out hemorrhage
✔ CT brain can be normal in posterior stroke
🧩 Take-Home Algorithm
1️⃣ Confirm true vertigo
2️⃣ Assess duration & trigger
3️⃣ Check hearing
4️⃣ Examine nystagmus
5️⃣ Perform head impulse & HINTS
6️⃣ Look for red flags
7️⃣ Order MRI if central suspected
📍 Early recognition saves cerebellum.
📍 Never discharge a patient who cannot walk independently.
Dr Muhammad Kashif Khaskheli
Pediatrician | Clinical Educator
