Vertigo is a symptom, not a diagnosis, defined as the false sensation of spinning, swaying, or moving. While many cases originate in the inner ear, a neurologist is consulted when the spinning sensation is traced to the central nervous system (the brain or brainstem). Neurological evaluation is the necessary step for identifying and managing vertigo that arises from conditions affecting the central balance centers. The distinction between the location of the problem—inner ear versus brain—determines the most appropriate medical specialist.
The Two Main Categories of Vertigo
Vertigo is categorized into two types based on origin: peripheral and central.
Peripheral Vertigo
Peripheral vertigo is the most common form, arising from issues within the inner ear or the vestibular nerve. This type typically causes intense spinning episodes that are brief, often lasting seconds to minutes, and are frequently triggered by head movements. Common peripheral causes include Benign Paroxysmal Positional Vertigo (BPPV), Meniere’s disease, or vestibular neuritis, which may also involve hearing loss and ringing in the ears.
Central Vertigo
Central vertigo originates from dysfunction in the brain, specifically the brainstem or the cerebellum. The spinning sensation is often described as less intense but more constant and persistent, lasting for hours or days. Unlike the peripheral form, central vertigo may not be triggered by changes in head position and is less likely to involve hearing problems. This category is generally associated with more serious underlying medical conditions.
When Neurological Consultation is Essential
A referral to a neurologist is needed when vertigo is suspected to be central in origin or when specific “red flag” symptoms accompany the spinning sensation. These warning signs indicate that the problem may be related to the brainstem or cerebellum and require immediate investigation. Symptoms such as sudden difficulty walking, severe imbalance disproportionate to the dizziness, or new, severe headaches are indicators of a central cause.
Specific neurological disorders frequently present with vertigo, including Vestibular Migraine, which is the most common central cause. This condition causes recurring episodes of vertigo that may occur with or without a headache, and the attacks can last from minutes to days. Vertigo may also be the first or only symptom of a stroke or transient ischemic attack (TIA) affecting the posterior circulation. Other causes include lesions from Multiple Sclerosis (MS) in the brainstem, which can disrupt the central balance pathways, and certain types of brain tumors. The presence of non-vestibular symptoms, such as double vision, facial numbness, or slurred speech, almost always necessitates an urgent neurological evaluation.
Diagnostic Tools Used by Neurologists
Neurologists employ a focused approach to distinguish between peripheral and central vertigo, beginning with a detailed neurological examination. This exam includes gait and balance testing to assess coordination and stability, looking for signs of severe disequilibrium that point toward a central issue. A specialized bedside tool called the HINTS exam is frequently used in acute cases to quickly differentiate the two categories. HINTS evaluates three components:
- The Head Impulse Test
- The pattern of Nystagmus (involuntary eye movements)
- The Test of Skew (vertical eye misalignment)
A normal result on the Head Impulse Test, or the presence of nystagmus that changes direction upon gaze, strongly suggests a central problem in the brainstem or cerebellum. If a central cause like a stroke or MS is suspected, neuroimaging is the next step. Magnetic Resonance Imaging (MRI) is the preferred method, as it provides high-resolution images of the posterior fossa, allowing the neurologist to visualize damage such as infarction, hemorrhage, or demyelinating lesions. Some neurologists also utilize Video Nystagmography (VNG) to objectively record and analyze eye movements, confirming the location of the vestibular dysfunction.
Neurological Approaches to Vertigo Management
Management of central vertigo differs significantly from treatments for inner ear causes because the goal is to address the underlying neurological disorder. For conditions like Vestibular Migraine, treatment focuses on prevention through prophylactic medications, such as certain anti-seizure drugs or beta-blockers. These medications work to stabilize the neural networks in the brain prone to migrainous activity. Similarly, if MS is the cause, the neurologist will manage the disease with disease-modifying therapies to reduce the likelihood of new lesions that could affect the balance centers.
A key component of managing chronic imbalance from central causes is Vestibular Rehabilitation Therapy (VRT). VRT is a specialized form of physical therapy that uses targeted exercises to encourage the brain to compensate for the faulty balance signals. This process, known as central compensation, helps the brain rely more on alternative sensory inputs, like vision and proprioception, to maintain stability. When the cause is a stroke, treatment focuses on minimizing risk factors and recovery, with VRT playing a large role in restoring function and improving walking stability.