Category · 1
Vertigo
The illusion of motion — usually spinning. Vertigo is the most distinctive kind of dizziness, and the one where telling peripheral from central can be life-saving.
- Onset & severitySudden, often intense spinning
- NystagmusUnidirectional, horizontal; suppressed by fixation
- HearingMay be affected (Ménière's, labyrinthitis)
- Other neuro signsAbsent
- Typical causesBPPV, vestibular neuritis, Ménière's
- ActionBedside diagnosis; reposition / rehabilitate
Peripheral vertigo
Vertigo means feeling that you — or the world — are moving when you're not, because the inner-ear balance organ is sending the brain a false signal. Most vertigo comes from the inner ear itself (“peripheral”) and, while unpleasant, is usually treatable.
The big three are BPPV (brief spins on moving the head), vestibular neuritis (one long bout, no hearing loss), and Ménière's disease(attacks with hearing changes).
Peripheral vertigo arises from the labyrinth or vestibular nerve. BPPV — the commonest — gives brief, position-triggered vertigo from otoconia displaced into a semicircular canal, and responds to repositioning manoeuvres.1,2 Vestibular neuritis is an acute, self-limited inflammation of the vestibular nerve: abrupt vertigo over hours to days, with nausea and imbalance but no hearing loss.3
Ménière's disease is more complex — endolymphatic hydrops producing episodic vertigo (20 minutes to hours) with fluctuating hearing loss, tinnitus, and aural fullness.4
The peripheral signature is intense, often abrupt vertigo with unidirectional, fixation-suppressed nystagmus and intact other cranial nerves. Duration and auditory involvement separate the trio: seconds and positional (BPPV), a single sustained bout without hearing loss (neuritis), or recurrent attacks with cochlear fluctuation (Ménière's).
How long do attacks last?
Duration is the single most useful discriminator among the peripheral causes — and the reason the same patient question (“how long does a spell last?”) is worth asking first.
Tap a bar to read its typical pattern. Time axis is logarithmic.
Central vertigo — never miss it
A smaller share of vertigo comes from the brain (“central”) — the brainstem or cerebellum. It can feel milder than inner-ear vertigo, but it can be a stroke, so the warning signs matter.
Central vertigo arises from the brainstem, cerebellum, or cortex — posterior-circulation stroke, multiple sclerosis, or a cerebellar tumour. Look for accompanying neurological signs: diplopia, dysarthria, limb ataxia, and especially vertical or direction-changing nystagmus that is not suppressed by visual fixation. These mandate urgent posterior-fossa MRI.5
The paradox to teach: central vertigo is often less severe than peripheral vertigo, yet far more dangerous. In the acute vestibular syndrome, bedside oculomotor signs (a normal head impulse, direction-changing nystagmus, or skew) outperform early MRI for stroke,5so a benign-sounding history must never override an alarming examination.
- Spinning / rotation
Ask“Does the room — or you — feel like it's spinning, tilting, or being pulled?”
A true illusion of motion = vertigo, from the vestibular system (peripheral or central).
BPPVVestibular neuritisMénière's diseaseVestibular migraine - Brief, position-triggered spins
Ask“Do the spins last only seconds, brought on by lying down or rolling over?”
Brief positional vertigo with normal hearing — peripheral BPPV.
BPPV - Spinning + hearing change
Ask“Are attacks (20 min–hours) accompanied by fluctuating hearing, tinnitus, or fullness?”
Episodic vertigo with cochlear symptoms — Ménière's disease.
Ménière's disease - Vertigo + neurological signs▲ red flag
Ask“Any double vision, slurred speech, limb ataxia, or vertical/direction-changing nystagmus?”
Central vertigo — needs urgent posterior-fossa MRI; severity is often mild but the danger is high.
Posterior circulation strokeMultiple sclerosisCerebellar tumour