The history · 4
The company it keeps
Vertigo is rarely the discriminator — the symptoms around it are. Auditory features localise to the inner ear; neurological features raise the spectre of a central lesion.
Auditory symptoms — the labyrinthine fingerprint
Hearing symptoms are a powerful clue, because the balance organ and the hearing organ sit side by side in the inner ear. If vertigo comes with hearing loss, ringing, or a feeling of fullness in one ear, the problem is probably in the ear itself rather than the brain.
Episodic vertigo with fluctuating low-frequency hearing loss, tinnitus, and aural fullness is the hallmark of Ménière's disease, attributed to endolymphatic hydrops.1,2 Sudden hearing loss with acute vertigo suggests labyrinthitis; progressive asymmetric loss with mild imbalance suggests vestibular schwannoma. Crucially, the absence of auditory symptoms makes a labyrinthine cause unlikely and steers you toward vestibular neuritis or a central process.
The audiovestibular pairing is diagnostically decisive but has a dangerous exception: an AICA-territory infarct can produce acute vertigo with hearing loss by infarcting the labyrinth, mimicking a peripheral lesion. This is precisely why bedside hearing testing is folded into HINTS Plus. Hearing loss with vertigo and a facial palsy points instead to a CPA tumour or herpes zoster oticus.5
- Fluctuating hearing + tinnitus + vertigo
Ask“Have you had vertigo with fluctuating hearing and ringing in one ear?”
Recurrent vertigo with low-frequency SNHL, tinnitus, and aural fullness — Ménière's disease (endolymphatic hydrops).
Ménière's disease - Sudden hearing loss with vertigo
Ask“Did your hearing drop suddenly before or during the dizziness?”
Acute cochleo-vestibular involvement — labyrinthitis; an AICA stroke can mimic this and must be excluded.
LabyrinthitisPosterior circulation stroke - Progressive unilateral loss
Ask“Has hearing in one ear declined gradually, with constant tinnitus?”
Progressive asymmetric SNHL with mild imbalance suggests vestibular schwannoma — image with gadolinium MRI.
Vestibular schwannoma - Aural fullness
Ask“Do you feel pressure or fullness in the ear during or before episodes?”
Aural fullness is seen in Ménière's disease and perilymph fistula.
Ménière's diseasePerilymph fistula - No auditory symptoms
Ask“Have you noticed any change in hearing or any ringing in the ears?”
Normal hearing favours vestibular neuritis (nerve-only) or a central cause — both typically spare the cochlea.
Vestibular neuritisPosterior circulation strokeMultiple sclerosis
Neurological symptoms — central until proven otherwise
Some symptoms should always raise alarm: double vision, slurred speech, difficulty swallowing, weakness or numbness down one side, or being unable to walk unaided. These suggest the problem is in the brain, not the ear, and need urgent attention.
Central vertigo arises from the brainstem, cerebellum, or central pathways and is usually accompanied by other deficits — diplopia, dysarthria, dysphagia, hemiparesis, or truncal ataxia out of proportion to the vertigo. Persistent vertigo that does not improve with visual fixation, or that is associated with vertical or direction-changing nystagmus, is a central sign.4
In the acute vestibular syndrome, bedside oculomotor testing (HINTS) outperforms early MRI-DWI for stroke when performed by trained examiners.3 The history primes the examination: continuous spontaneous vertigo with any central symptom, or with vascular risk factors, lowers the threshold to treat the presentation as central until HINTS and imaging say otherwise. Use the toggle below to compare the two patterns.
Abnormal — a corrective catch-up saccade on rapid head turn toward the affected side.
Unidirectional, horizontal, suppressed by visual fixation (obeys Alexander's law).
Absent — no vertical realignment on the alternate cover test.
- Diplopia▲ red flag
Ask“Did you have blurred or double vision during the episode?”
Suggests brainstem/cerebellar involvement — posterior-circulation stroke or demyelination.
Posterior circulation strokeMultiple sclerosis - Dysarthria▲ red flag
Ask“Did your speech become slurred during your episodes?”
May indicate brainstem stroke or TIA.
Posterior circulation stroke - Dysphagia▲ red flag
Ask“Did you have any difficulty swallowing during or after the dizziness?”
Suggests medullary infarction (e.g., Wallenberg) or cranial-nerve involvement.
Posterior circulation stroke - Hemiparesis / sensory loss▲ red flag
Ask“Have you felt weakness or numbness down one side of the body?”
A strong red flag for central vertigo — stroke or multiple sclerosis.
Posterior circulation strokeMultiple sclerosis - Severe new headache▲ red flag
Ask“Have you had a severe, new, or different headache — especially at the back of the head?”
Consider vertebrobasilar ischaemia, posterior-fossa haemorrhage, or vascular dissection.
Posterior circulation stroke - Ataxia not helped by fixation▲ red flag
Ask“Are you so unsteady that you cannot walk without support?”
Truncal ataxia out of proportion to the vertigo points to cerebellar stroke or tumour.
Posterior circulation stroke