The differential diagnosis of vertigo can be broken into peripheral and central causes. It is imperative the Emergency Physician consider central causes of vertigo.
Signs/ Symptoms Differentiating Peripheral and Central Vertigo
| Peripheral | Central | |
| Onset | Sudden or Insidious | Sudden |
| Severity of Vertigo | Intense Spinning | Ill-defined, may be severe or less intense |
| Prodromal Dizziness | Occurs in up to 25%, often single episode | Occurs in up to 25%, recurrent episodes suggest TIA’s |
| Intolerant of head movements/Dix-Hallpike Maneuver | Yes | Varies, but often intolerant |
| Associated Nausea/Diaphoresis | Frequent | Variable, but often frequent |
| Auditory Symptoms | Points to peripheral causes | May be present |
| Proportionality of Symptoms | Usually proportional | Often disproportionate |
| Headache/Neck Pain | Unusual | More likely |
| CNS signs/symptoms | Absent | Usually present |
| Head Impulse Test | Abnormal | Often normal |
| Nystagmus | Horizontal | Vertical/direction-changing |
| HINTS Testing | Negative | Abnormal in at least 1 out of 3 tests |
