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Red flags in assessing acute vertigo

Red flags in assessing acute vertigo

As part of our Pulse Live series highlighting sessions at the events, Dr Goubran Eskander, GP and expert in ENT, explains the symptoms, tests and examinations relevant to acute vertigo

Acute vertigo is a common presentation. It is often unsettling for the patient and can arise from a variety of underlying causes. A targeted history, relevant past medical history, and thorough clinical examination play pivotal roles in identifying red flags that may indicate a rare central cause.

Distinguishing central from peripheral vertigo

 Central vertigo is rare but important to spot because it requires immediate attention and action due to its association with potentially serious underlying conditions. The key question in evaluating this symptom is whether it is central or peripheral.

Central vertigo is usually attributed to lesions within the brainstem or cerebellum, while peripheral vertigo stems from issues within the inner ear or vestibular nerve.


A comprehensive history-taking process is crucial in assessing acute vertigo and determining its underlying cause. Peripheral vertigo is far more common in clinical practice. Specific symptoms can help distinguish between a central or peripheral cause:

  • Otological symptoms: Inquire about hearing loss, ear discharge, a sense of fullness in the ear, or tinnitus. These symptoms point towards a peripheral cause. Important to note that sudden hearing loss (sensorineural) with vertigo can also be present in acute posterior circulation ischemia
  • Neurological symptoms: Pay attention to neurological symptoms such as headaches, diplopia, speech difficulties, paraesthesia, muscle weakness, and ataxia. FAST symptoms suggest a possible TIA or CVA. All these features may suggest central pathology.

Relevant past and recent medical history

The following factors will give further clues to aetiology.

  • Recent or ongoing URTI may predispose to peripheral vertigo, as viral infections can cause vestibular neuritis, labyrinthitis or even induce inner ear inner ear canalithiasis (BPPV).
  • A history of migraines is relevant, as migrainous vertigo or vestibular migraine is more prevalent in clinical practice than commonly believed.
  • Recent head trauma can lead to central vertigo, warranting an urgent assessment.
  • Cardiovascular and metabolic conditions such as hypertension, diabetes, or a history of stroke increase the chances of of central vertigo.
  • Excessive alcohol consumption can affect the central nervous system and contribute to central vertigo.

Clinical examination

A focused clinical examination is essential in differentiating between central and peripheral vertigo. Key elements of the examination include:

  • HINTS examination. The Head Impulse, Nystagmus, Test of Skew examination is a critical tool, though not very sensitive or specific, in assessing acute vestibular syndrome and central vertigo. It involves evaluating head impulses, nystagmus patterns, and skew deviation of the eyes.
  • Neurological examination. A thorough neurological assessment can reveal deficits that may indicate central pathology, such as cranial nerve abnormalities, weakness, or sensory changes.
  • Gait and postural stability. Assessing gait and postural stability is important in identifying signs of cerebellar dysfunction.
  • Otoscopy. Examination of the ears can reveal signs of infection or injury that may contribute to peripheral vertigo.

Additional tests

Romberg’s and Unterberger’s tests can provide supplementary information. Romberg’s test assesses postural stability with eyes closed. Romberg has very low specificity to differentiate central from peripheral vertigo. Unterberger test, when abnormal, is very specific to unilateral labyrinth dysfunction.

Hallpike’s Manoeuvre is typically used for diagnosing benign paroxysmal positional vertigo (BPPV). If positive, it is specific, although it is not always positive in every patient with BPPV at time of clinical examination.


Acute vertigo is a multifaceted symptom that requires careful evaluation to identify potential underlying central or peripheral causes. Distinguishing between the two is crucial due to the implications for treatment and management. A targeted history, consideration of relevant past medical history, and a thorough clinical examination are indispensable in recognizing red flags that may indicate central vertigo. By incorporating tools like the HINTS examination, neurological assessment, and specific tests, healthcare professionals can more effectively differentiate between central and peripheral vertigo, ultimately leading to timely and appropriate interventions.

Dr Goubran Eskander is a GPSI in ENT, St Helens and Knowsley Teaching Hospitals NHS Trust


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