Peripheral vs Central Vertigo Differentiator
Prerequisite: Dizziness has already been classified as vestibular (worsened by head movement, nystagmus present or Dix-Hallpike positive). Use this skill to determine if the cause is peripheral or central.
Step 1 — Assess the Nystagmus
Nystagmus is the single most informative bedside sign. Examine for:
- Spontaneous nystagmus (at rest, eyes forward)
- Gaze-evoked nystagmus (looking left, right, up, down)
- Positional nystagmus (after Dix-Hallpike)
Tip: Subtle nystagmus may only be visible with fixation blocked — have the patient gaze through a white sheet of paper held close to the eyes.
| Feature |
Peripheral |
Central |
| Direction |
Unidirectional; fast component toward the normal ear; never reverses |
May reverse direction when patient looks in direction of slow component; can be purely vertical or torsional |
| Type |
Horizontal with torsional component; never purely torsional or vertical |
Any direction; purely vertical or purely torsional = central sign |
| Effect of visual fixation |
Suppressed by fixation |
Not suppressed — persists or worsens with fixation |
| Postural instability |
Mild-moderate; walking preserved |
Severe; patient may fall when walking |
| Deafness / tinnitus |
May be present |
Usually absent |
| Other neurologic signs |
Absent |
Often present (diplopia, ataxia, dysarthria, dysphagia, focal weakness) |
🚨 Central red flags in nystagmus:
- Direction-changing nystagmus
- Purely vertical or purely torsional nystagmus
- Nystagmus NOT suppressed by visual fixation
Step 2 — Perform and Interpret Dix-Hallpike
Technique: Move patient rapidly from sitting → lying with head tilted 45° off the table and rotated 45° to one side. Observe eyes for nystagmus.
| Feature |
Peripheral (BPPV) |
Central |
| Latent period |
2–20 seconds |
None (immediate onset) |
| Duration of nystagmus |
< 1 minute |
> 1 minute |
| Fatigability |
Fatigues with repetition |
Nonfatiguing |
| Intensity of vertigo |
Severe |
Less severe, sometimes none |
✅ BPPV diagnosis: Typical Dix-Hallpike response (latency 2–20s, duration <1 min, fatigues, severe vertigo) = 80% sensitivity for BPPV
⚠️ Atypical Dix-Hallpike (immediate onset, non-fatiguing, duration >1 min, minimal vertigo) = central cause until proven otherwise
Step 3 — Look for Brainstem / Cerebellar Signs
Perform a focused neurologic exam:
Central signs (any one of these = flag for neuroimaging):
- Cranial nerve abnormalities (diplopia, facial sensory loss, dysarthria, dysphagia)
- Horner syndrome
- Motor or sensory deficits (especially hemibody)
- Dysmetria on finger-nose or heel-shin testing
- Severely ataxic gait — patient falls or cannot walk
- Skew deviation (vertical misalignment of eyes)
- Abnormal head impulse test (HIT) when combined with direction-changing nystagmus or skew (HINTS exam)
⚠️ Absence of other neurologic signs does NOT fully exclude a central process. Isolated cerebellar strokes can present with dizziness alone.
Step 4 — Assess Hearing
| Finding |
Interpretation |
| Unilateral hearing loss + vertigo |
Strongly suggests peripheral cause (labyrinthitis, Ménière's disease) |
| Tinnitus + ear fullness + recurrent attacks |
Ménière's disease — peripheral |
| No hearing loss |
Does NOT exclude peripheral disease |
| Sudden hearing loss + vertigo |
Consider labyrinthine infarct — urgent imaging |
Step 5 — Pattern-Based Diagnosis
| Clinical Pattern |
Most Likely Diagnosis |
Action |
| Acute prolonged severe vertigo, normal neuro exam, normal HIT |
Vestibular neuritis |
Peripheral; supportive management |
| Acute prolonged vertigo + ataxic gait or brainstem signs |
Cerebellar/brainstem stroke |
Urgent neuroimaging |
| Recurrent brief positional spells, positive Dix-Hallpike (typical) |
BPPV |
Epley maneuver |
| Atypical Dix-Hallpike response + hearing loss |
Posterior fossa lesion |
Further investigation |
| Recurrent attacks + hearing loss/tinnitus/fullness |
Ménière's disease |
Peripheral; refer audiology/ENT |
| Recurrent unprovoked attacks + migrainous features |
Vestibular migraine |
Peripheral; neurology/migraine workup |
Clinical Guardrails
- HINTS exam (Head Impulse, Nystagmus direction, Test of Skew) — when all three are assessed together in acute prolonged vertigo, an abnormal HIT + unidirectional nystagmus + no skew = peripheral. Any component suggesting central = neuroimaging urgently.
- "Normal" MRI does not exclude early posterior fossa stroke — MRI within 24–48 hours of cerebellar stroke may be falsely negative. Clinical suspicion should drive management.
- Positional vertigo ≠ BPPV by default — atypical Dix-Hallpike warrants imaging for posterior fossa lesion.
- Vestibular dizziness ≠ peripheral — always complete a neurologic exam before labelling as benign.
Source: Barton JS. "Approach to the patient with dizziness." UpToDate. Last updated Dec 11, 2025.
1---2name: peripheral-vs-central-vertigo3description: Peripheral vs Central Vertigo Differentiator4---56# Peripheral vs Central Vertigo Differentiator78> **Prerequisite:** Dizziness has already been classified as vestibular (worsened by head movement, nystagmus present or Dix-Hallpike positive). Use this skill to determine if the cause is peripheral or central.910---1112## Step 1 — Assess the Nystagmus1314Nystagmus is the single most informative bedside sign. Examine for:151. Spontaneous nystagmus (at rest, eyes forward)162. Gaze-evoked nystagmus (looking left, right, up, down)173. Positional nystagmus (after Dix-Hallpike)1819**Tip:** Subtle nystagmus may only be visible with fixation blocked — have the patient gaze through a white sheet of paper held close to the eyes.2021| Feature | Peripheral | Central |22|---|---|---|23| Direction | Unidirectional; fast component toward the normal ear; **never reverses** | May reverse direction when patient looks in direction of slow component; can be purely vertical or torsional |24| Type | Horizontal with torsional component; never purely torsional or vertical | Any direction; **purely vertical or purely torsional = central sign** |25| Effect of visual fixation | **Suppressed** by fixation | **Not suppressed** — persists or worsens with fixation |26| Postural instability | Mild-moderate; walking preserved | Severe; patient may fall when walking |27| Deafness / tinnitus | May be present | Usually absent |28| Other neurologic signs | **Absent** | Often present (diplopia, ataxia, dysarthria, dysphagia, focal weakness) |2930> 🚨 **Central red flags in nystagmus:**31> - Direction-changing nystagmus32> - Purely vertical or purely torsional nystagmus33> - Nystagmus NOT suppressed by visual fixation3435---3637## Step 2 — Perform and Interpret Dix-Hallpike3839**Technique:** Move patient rapidly from sitting → lying with head tilted 45° off the table and rotated 45° to one side. Observe eyes for nystagmus.4041| Feature | Peripheral (BPPV) | Central |42|---|---|---|43| Latent period | 2–20 seconds | **None** (immediate onset) |44| Duration of nystagmus | < 1 minute | > 1 minute |45| Fatigability | **Fatigues with repetition** | Nonfatiguing |46| Intensity of vertigo | Severe | Less severe, sometimes none |4748> ✅ **BPPV diagnosis:** Typical Dix-Hallpike response (latency 2–20s, duration <1 min, fatigues, severe vertigo) = 80% sensitivity for BPPV49>50> ⚠️ **Atypical Dix-Hallpike** (immediate onset, non-fatiguing, duration >1 min, minimal vertigo) = central cause until proven otherwise5152---5354## Step 3 — Look for Brainstem / Cerebellar Signs5556Perform a focused neurologic exam:5758**Central signs (any one of these = flag for neuroimaging):**59- Cranial nerve abnormalities (diplopia, facial sensory loss, dysarthria, dysphagia)60- Horner syndrome61- Motor or sensory deficits (especially hemibody)62- Dysmetria on finger-nose or heel-shin testing63- Severely ataxic gait — patient falls or cannot walk64- Skew deviation (vertical misalignment of eyes)65- Abnormal head impulse test (HIT) when combined with direction-changing nystagmus or skew (HINTS exam)6667> ⚠️ **Absence of other neurologic signs does NOT fully exclude a central process.** Isolated cerebellar strokes can present with dizziness alone.6869---7071## Step 4 — Assess Hearing7273| Finding | Interpretation |74|---|---|75| Unilateral hearing loss + vertigo | Strongly suggests **peripheral** cause (labyrinthitis, Ménière's disease) |76| Tinnitus + ear fullness + recurrent attacks | Ménière's disease — peripheral |77| No hearing loss | Does NOT exclude peripheral disease |78| Sudden hearing loss + vertigo | Consider labyrinthine infarct — urgent imaging |7980---8182## Step 5 — Pattern-Based Diagnosis8384| Clinical Pattern | Most Likely Diagnosis | Action |85|---|---|---|86| Acute prolonged severe vertigo, normal neuro exam, normal HIT | Vestibular neuritis | Peripheral; supportive management |87| Acute prolonged vertigo + ataxic gait or brainstem signs | Cerebellar/brainstem stroke | **Urgent neuroimaging** |88| Recurrent brief positional spells, positive Dix-Hallpike (typical) | BPPV | Epley maneuver |89| Atypical Dix-Hallpike response + hearing loss | Posterior fossa lesion | Further investigation |90| Recurrent attacks + hearing loss/tinnitus/fullness | Ménière's disease | Peripheral; refer audiology/ENT |91| Recurrent unprovoked attacks + migrainous features | Vestibular migraine | Peripheral; neurology/migraine workup |9293---9495## Clinical Guardrails9697- **HINTS exam** (Head Impulse, Nystagmus direction, Test of Skew) — when all three are assessed together in acute prolonged vertigo, an abnormal HIT + unidirectional nystagmus + no skew = peripheral. Any component suggesting central = neuroimaging urgently.98- **"Normal" MRI does not exclude early posterior fossa stroke** — MRI within 24–48 hours of cerebellar stroke may be falsely negative. Clinical suspicion should drive management.99- **Positional vertigo ≠ BPPV by default** — atypical Dix-Hallpike warrants imaging for posterior fossa lesion.100- **Vestibular dizziness ≠ peripheral** — always complete a neurologic exam before labelling as benign.101102---103104*Source: Barton JS. "Approach to the patient with dizziness." UpToDate. Last updated Dec 11, 2025.*
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