The history · 6
Red flags
Most vertigo is benign and self-limiting. The purpose of red-flag screening is to find the minority that is not — before it declares itself.
- Acute vertigo + focal neurology
Strongly suggests brainstem or cerebellar stroke — immediate neuroimaging required.
Ask“Any weakness, numbness, double vision, or speech/swallow difficulty with the vertigo?”
- Sudden severe headache
May indicate vertebrobasilar ischaemia or posterior-circulation infarction/haemorrhage.
Ask“Did a sudden, severe, or 'worst-ever' headache accompany the vertigo?”
- Vertical / direction-changing nystagmus
Characteristic of a central lesion — demyelination or stroke.
Ask“Has an examiner seen vertical or direction-changing nystagmus?”
- Hearing loss + facial palsy
Suggests a CPA tumour (vestibular schwannoma) or herpes zoster oticus (Ramsay Hunt syndrome).
Ask“Is the vertigo accompanied by hearing loss and facial weakness?”
- Persistent despite treatment
Raises suspicion of a central origin, PPPD, or bilateral vestibulopathy.
Ask“Have symptoms persisted despite appropriate therapy or repositioning?”
- Non-fatiguing positional vertigo
Points to central positional vertigo — cerebellar degeneration or infarction.
Ask“Is the positional vertigo non-fatiguing or direction-changing on testing?”
Why red flags matter
A few features should always make you stop and think “could this be a stroke or something serious?” — sudden severe headache, double vision, slurred speech, weakness, or being unable to walk. Any one of them outweighs an otherwise reassuring story and needs urgent assessment.
The chief concern is a brainstem or cerebellar stroke presenting as vertigo.1 Focal neurological deficits, vertical or direction-changing nystagmus, a severe new headache, and profound truncal ataxia are all central signs. The combination of acute hearing loss, vertigo, and facial palsy points to a CPA tumour or Ramsay Hunt syndrome.4
Bedside oculomotor signs (HINTS) interpreted by a trained examiner detect stroke more sensitively than early MRI in the acute vestibular syndrome,3 because diffusion-weighted imaging misses a meaningful fraction of small posterior-fossa strokes in the first 24–48 hours.2 A non-fatiguing or direction-changing positional nystagmus should likewise be treated as central until proven otherwise. The history's job is to lower the threshold for these examinations and for imaging.
Never miss
- Acute vertigo with any focal neurological sign → immediate neuroimaging.
- A normal head impulse in continuous spontaneous vertigo → think central, not peripheral.
- Vertical or direction-changing nystagmus → central until proven otherwise.
- Vertigo + acute hearing loss + facial palsy → CPA lesion or Ramsay Hunt.
- Symptoms refractory to correct treatment → reconsider the diagnosis.