Vertigo vs Stroke: How to Tell the Difference — A Question That Can Save a Life

Sudden severe dizziness or vertigo is one of the most challenging presentations in emergency medicine — because the same symptom can be caused by the most common (and benign) neurological condition (BPPV) or by the most dangerous acute neurological emergency (posterior circulation stroke). Getting it wrong in either direction has serious consequences: missing a stroke leads to death or permanent disability; over-investigating every dizzy patient with CT scans and hospital admissions is expensive and exposes patients to unnecessary radiation and anxiety.

Features Favouring Benign Peripheral Vertigo

BPPV: Triggered by a specific head position (rolling over in bed, looking up); brief (under 60 seconds); stops completely when the head is still; no other neurological symptoms; positive Dix-Hallpike test with upbeat-torsional nystagmus that fatigues with repeated testing. Vestibular neuritis: Sudden severe continuous vertigo; no hearing loss; no neurological symptoms; horizontal nystagmus that reduces with visual fixation; preceded by upper respiratory tract infection. History of similar attacks suggests vestibular migraine or Menière's disease — episodic benign disorders.

Features Demanding Urgent Stroke Evaluation

Any ONE of these in a patient with acute dizziness: neurological symptoms (diplopia, dysarthria, dysphagia, facial numbness, limb weakness or numbness, gait ataxia — inability to walk without support); sudden severe headache accompanying the dizziness; nystagmus that changes direction when gaze direction changes; inability to walk (even if there is no limb weakness — pure gait ataxia is a cerebellar stroke sign until proven otherwise); vascular risk factors (hypertension, diabetes, atrial fibrillation, smoking) in an older patient.

The HINTS Exam at the Bedside

For acute spontaneous continuous vertigo (not positional), the HINTS exam (Head Impulse, Nystagmus, Test of Skew) has greater sensitivity for posterior fossa stroke than MRI DWI in the first 24 hours. A normal head impulse test, direction-changing nystagmus, or skew deviation in a patient with continuous acute vertigo = central cause = urgent MRI + neurology. Sri Anand CNC, Chanda Nagar, Hyderabad. Call +91 90633 66983.