Peripheral Vertigo Diagnosis and Characteristics

Key Distinguishing Features

Auditory symptoms, including tinnitus, fluctuating hearing loss, and aural fullness, are hallmark features of peripheral vestibular pathology, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 3
The American College of Radiology recommends considering vestibular neuritis, labyrinthitis, benign paroxysmal positional vertigo (BPPV), and Ménière's disease as common peripheral causes of vertigo 4, 5
Horizontal or horizontal-rotatory nystagmus suggests a peripheral cause, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 2
The presence of tinnitus, hearing loss, or aural fullness strongly favors a peripheral cause, according to the American Academy of Otolaryngology-Head and Neck Surgery 1, 3

The American College of Radiology suggests that the presence of cranial nerve deficits, such as diplopia, dysphagia, or dysarthria, indicates a central cause requiring urgent neuroimaging 4, 5
Isolated vertigo without focal neurologic signs is likely peripheral, but 11-25% may still have posterior circulation stroke, as noted by the American College of Radiology 4, 6
The American Academy of Otolaryngology-Head and Neck Surgery states that pure vertical nystagmus strongly suggests a central cause 1, 2

The American College of Radiology advises against assuming a normal neurologic examination excludes stroke, as up to 75-80% of patients with acute vestibular syndrome from posterior circulation infarction may lack focal neurologic deficits 4, 6
The American Academy of Otolaryngology-Head and Neck Surgery recommends considering imaging in patients over 50 years with vascular risk factors, or when severe imbalance is out of proportion to vertigo, suggesting cerebellar involvement 4
The American College of Radiology suggests that a HINTS examination suggesting central cause, including absent head impulse test, direction-changing nystagmus, or vertical skew deviation, warrants imaging 4, 5