The Biggest Lie About Vertigo — It Is NOT Always From the Ear

The word "vertigo" has been reduced in popular understanding to mean "dizziness from the ear." Patients are told to take betahistine, do the Epley manoeuvre, and wait. For BPPV (benign paroxysmal positional vertigo) — the most common cause — this is entirely appropriate. But a significant minority of patients with vertigo have central causes — from the brain and brainstem — that require urgent neurological evaluation. Missing a posterior fossa stroke because it was labelled "just an ear problem" is a preventable tragedy.

Peripheral Vertigo (Ear/Vestibular Origin) — Usually Benign

BPPV: Triggered by head position changes — rolling over in bed, looking up, bending down. Brief (under 60 seconds per episode). Horizontal or upbeat-torsional nystagmus on the Dix-Hallpike test. Treated by Epley manoeuvre. No hearing loss, no neurological symptoms.

Vestibular neuritis: Sudden severe vertigo lasting days with gradual resolution over weeks. Often follows a viral illness. Persistent horizontal nystagmus, no hearing loss. Treated with vestibular suppressants acutely and vestibular rehabilitation exercises.

Menière's disease: Episodes lasting 20 minutes to several hours. Accompanied by low-frequency hearing loss, ear fullness, and tinnitus. Fluctuating.

Central Vertigo (Brain/Brainstem) — Potentially Serious

Central vertigo comes from the cerebellum and brainstem — and can be caused by stroke, TIA, multiple sclerosis, or posterior fossa tumours. The key distinguishing features:

Feature	Peripheral (ear)	Central (brain)
Onset	Acute, often positional	Sudden (stroke) or gradual
Nystagmus direction	Unidirectional, reduces with fixation	Direction-changing, persists with fixation
Hearing loss	Possible (Menière's)	Rarely
Other neurology	None	Double vision, facial numbness, dysarthria, limb ataxia
HINTS exam	Negative	Positive — any one of: abnormal head impulse test, direction-changing nystagmus, skew deviation

The HINTS Exam — More Sensitive Than MRI in the First 24 Hours

The HINTS (Head Impulse, Nystagmus, Test of Skew) bedside examination, performed by a trained clinician, has greater sensitivity for posterior fossa stroke than MRI DWI in the first 24–48 hours (when early infarcts are MRI-negative). A normal HINTS exam in a patient with acute continuous vertigo strongly suggests a central cause and requires urgent further evaluation.

For vertigo assessment and central vs peripheral differentiation: Sri Anand CNC, Chanda Nagar, Hyderabad. Call +91 90633 66983.