Key clinical features differentiating peripheral from central vertigo in adults include the onset, associated neurological signs, nystagmus characteristics, and response to specific clinical tests.
Peripheral vertigo typically presents with a sudden onset of vertigo that is often positional and accompanied by nausea and vomiting. It is usually associated with unidirectional, horizontal nystagmus that suppresses with visual fixation and a positive head impulse test indicating vestibular hypofunction. Peripheral causes often lack other neurological symptoms or signs. Common peripheral diagnoses include benign paroxysmal positional vertigo (BPPV), vestibular neuronitis, and Meniere's disease NICE CKS.
In contrast, central vertigo often has a hyperacute onset reaching maximum intensity within seconds and is persistent rather than positional. It is frequently accompanied by additional neurological features such as new headache (especially occipital), gait disturbance, truncal ataxia, cranial nerve deficits, sensory or limb weakness, and vertical or torsional nystagmus that does not suppress with visual fixation. The head impulse test is typically normal in central vertigo. Acute unilateral deafness without typical Meniere's features also raises suspicion for a central cause. These red flags necessitate urgent referral and neuroimaging to exclude brainstem stroke or other central pathology NICE CKS,NICE NG127.
The HINTS examination (Head-Impulse, Nystagmus, Test-of-Skew) is a valuable bedside tool: a normal head impulse test, direction-changing nystagmus, or skew deviation strongly suggest a central cause, whereas an abnormal head impulse test supports a peripheral cause. If a healthcare professional trained in HINTS is unavailable, urgent referral is recommended NICE NG127.
Recent systematic reviews support the diagnostic accuracy of these clinical features and the HINTS test in emergency settings, reinforcing guideline recommendations that emphasize the importance of neurological signs and specific eye movement findings in differentiating central from peripheral vertigo Shah et al. 2023.