Vertigo - an illusion of motion where no motion exists   (not to be confused with syncope/pre-syncope)

Seek details of:

  • Onset
  • Duration
  • Repetition
  • Hearing/tinnitus
  • Headache
  • Vomiting
  • Diplopia
  • Recent medication

Differentiate between central and peripheral vertigo, since the former are almost always a result of serious pathology

“Red flags” for posterior circulation stroke

  • Sudden onset vertigo or disequilibrium with one or more additional posterior circulation symptoms
    • Headache
    • Gait or limb ataxia
    • Visual change (diplopia or partial visual field loss)
    • Dysarthria, dysphagia
    • Limb weakness
  • Sudden onset vertigo or disequilibrium with a HINTS examination suggesting a central cause
  • Hx migraine, presentation with any new posterior circulation symptoms, even if these occur with headache

Ask a senior to review if there are any two new acute onset posterior circulation symptoms (especially if there are risk factors for stroke) or any new focal posterior circulation neurological signs.

Clinical signs


  • Less intense
  • Not positional
  • Hearing rarely affected
  • Nystagmus not inhibited by ocular fixation
  • Brain stem /cerebellar signs

Hallpike (with central)

  • No latency of nystagmus
  • Nystagmus non-fatiguing
  • Multidirectional
  • Vertigo lasts >1min


  • Intense spinning / swaying
  • Aggravated by position
  • Altered hearing / tinnitus
  • Horizontal nystagmus is unidirectional (unaffected by gaze direction)
  • Nystagmus inhibited by ocular fixation
  • Nystagmus fast phase worse looking away from damaged labyrinth

Hallpike (with peripheral)

  • 2-20s latency
  • fatigue with repeat testing
  • unidirectional
  • <1min
*patient sitting on trolley, rapidly lowered to supine position with physician controlling head. Head rotated 45 degrees left then right.
Examples of Common Peripheral, Central and Physiological patters of Nystagmus
Pattern Types Nystagmus Characteristics Typical causes

Peripheral patterns *

Burst of upbeat-torsional nystagmus, lasting < 30 seconds, triggered by the Dix-Hallpike test to one side.

Unidirectional spontaneous (i.e., primary gaze) nystagmus, with ↑ in velocity in the direction of the nystagmus fast phase and ↓ velocity in the opposite direction. E.g. left beating nystagmus in primary gaze, with an increase in velocity with left gaze, and a decrease (but not reversal) with right gaze.


Vestibular neuronitis (labyrinthitis)

Central Patterns

Spontaneous vertical nystagmus (upbeat or downbeat).

Gaze-evoked direction changing nystagmus (i.e., persistent left beating on left gaze and then persistent right beating on right gaze).

Persistent down-beating nystagmus triggered by a positional test such as the Dix-Hallpike test. §

Stroke, multiple sclerosis

Chiari malformation

Meds (e.g., antiepileptics) stroke, multiple sclerosis, cerebellar degenerative disorder

Physiological patterns

Persistent down-beating nystagmus triggered by a positional test such as the Dix-Hallpike test.


BPPV = benign paroxysmal positional vertigo.

*For peripheral vestibular nystagmus, the velocity of nystagmus typically increases by inhibiting visual fixation and decreases by encouraging visual fixation. However, the effect of visual fixation does not discriminate one peripheral vestibular disorder from another.

§ The Dix-Hallpike test is a specific positional test to asses for positional nystagmus. The patient sits upright and the head is turned about 45° to one side. The patient is then quickly guided by the physician down to a supine position with the head extended over the end of the examining table. In this position, the eyes are observed for nystagmus triggered by the test. The patient is then brought back to the sitting position and the test is then repeated with the head turned to the opposite side.

HINTS test


HINTS to try differentiate benign AVS from posterior circulation stroke.

Patients with Acute Vestibular Syndrome (AVS) typically show:

  • Acute onset (over seconds / hours) of vertigo
  • Nausea and/or vomiting
  • Gait unsteadiness in association with head-motion intolerance
  • Nystagmus lasting days to weeks

HI = Horizontal Head Impulse test (h-HIT)

Used to check for proper vestibular ocular reflex (VOR) function.

  • Ask patient to look at your nose
  • Rotate patient's head R and L 20° then rapidly back to mid-line
  • If patient's gaze can remain fixed on your nose, VOR is intact (normal)
  • Can't remain fixed = abnormal - possible bulbar stroke

N = Nystagmus test

Check for nystagmus - involuntary, rapid and repetitive movement of the eyes.

Most patients who present an AVS show a dominantly horizontal uniditectional (direction of nystagmus unaffected by changed in gaze direction) nystagmus, which beats only in one direction and increases in intensity when the patient looks in the direction of the nystagmus fast phase (AWAY from the offending labyrinth).

Patients with a central AVS will sometimes exhibit a change in the direction of eccentric gaze.

TS = Test of Skew

A vertical ocular misalignment which results from an imbalance in neural firing when there is a central stroke/lesion.

  • Patient looks at your nose
  • Cover, then rapidly uncover one eye
  • Look to see if the eye re-aligns
  • Repeat with other eye


A benign HINTS exam presents with:

  • Abnormal h-HIT but only in one direction. Abnormal h-HIT in more than one direction is suspicious for a central lesion
  • Direction-fixed horizontal nystagmus
  • Absent skew (and indicates no immediate brain imaging is required

A dangerous HINTS presents with:

  • Normal/untestable h-HIT
  • Direction-changing horizontal or vertical nystagmus
  • Present/untestable skew deviation and further imaging is required


A positive HINTS exam: 100% sensitive and 96% specific for the presence of a central lesion.

The HINTS exam is more sensitive and specific than general neurological signs or than MRI in detecting medullary/pontine stroke.


Causes of central vertigo

  • Cerebellar   -  CVA infarct/bleed  **
  • Brain-stem
    • CVA e.g. lateral medullary syndrome
    • other infarcts of caudal pons
    • neoplasm
    • MS
  • Trauma
    • Check signs base of skull fracture

Unilateral sensorineural loss needs tumour exclusion (ENT OPD). The whisper test with finger-rub distraction should be followed up with Rinne's and Weber's to establish basis of hearing deficit.

NOTE - cerebellar haemorrhage suggested by acute ataxia and vertigo ± headache ± nausea and vomiting with no paralysis is a neurosurgical emergency and requires urgent CT and neurosurgical opinion

Causes of peripheral vertigo

  • Meniere's  (triad)
    • Bouts of vertigo, tinnitus & progressive deafness
  • Vestibular neuronitis
    • no hearing loss
  • Benign Positional vertigo
    • particularly provoked by altered position
  • Drugs
    • aspirin affects the cochlea giving rise to tinnitus
    • aminoglycosides affect vestibular apparatus primarily
  • Suppurative labyrinthitis - from recurrent otitis media / mastoiditis etc
  • Acoustic schwannoma and meningioma
    • gradual onset, pre-ceded by hearing loss


Peripheral features positive

  • Stop triggering drugs if appropriate
  • Chronic hearing loss - discuss with ENT
  • ? Benign positional vertigo - try repositioning manoeuvre  Cochrane
  • Other - brief course stemetil & GP review
  • CUH Referral Vestibular Assmen / Mx

Central features positive

  • Treatment as per cause
  • Urgent CT if ? cerebellar lesion / base skull #
  • Neurology review if ? MS
  • Refer medics if ? CVA

Drug treatment

Check eBNF (left margin),   Stemetil 5mg tds,   Antihistamines (e.g. cyclizine PO tds)


Newman-Toker et al. HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness. Academic Emergency Medicine. Volume 20, Issue 10, pages 986–996, October 2013

Kattah JC, Talkad AV, Wang DZ, Hsieh YH, & Newman-Toker DE (2009). HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke; a journal of cerebral circulation, 40 (11), 3504-10 PMID: 19762709

Babak et al. Application of the ABCD2 Score to Identify Cerebrovascular Causes of Dizziness in the Emergency Department. Stroke. 2012; 43: 1484-1489

CUH Referral for Vestibular assessment and management.

Content by Dr William Sargent, Dr Íomhar O' Sullivan 20/11/2002. Reviewed by Dr ÍOS 20/02/04, 04/04/2005, 13/01/2007. Revised and updated by Dr ÍOS 30/08/2011. Last review Dr ÍO 15/06/21