Vertigo is the sensation of spinning, swaying, or tilting, representing a false sense of motion. This symptom originates from a disruption in the body’s balance system, which involves the inner ear, eyes, and central nervous system. Neurologists manage patients experiencing vertigo when the origin of this disorienting sensation lies within the brain or brainstem. The neurologist’s goal is to determine if the vertigo is a symptom of a serious underlying neurological disorder.
The Neurologist’s Focus in Vertigo Management
The management of vertigo requires distinguishing between problems in the inner ear (peripheral vertigo) and issues in the central nervous system (central vertigo). Otolaryngologists (ENT specialists) typically address peripheral vertigo, caused by dysfunction in the inner ear or vestibular nerve. Conversely, neurologists focus on central vertigo, which results from issues affecting the brainstem, cerebellum, or their connections. These central areas integrate the sensory information needed to maintain balance and spatial orientation.
A neurologist’s expertise is required when vertigo manifests as a neurological disease process. Common causes include cerebrovascular events, such as a stroke affecting the posterior circulation of the brain. Vertigo can also relate to chronic conditions like multiple sclerosis (MS), where demyelination lesions affect balance centers in the brainstem or cerebellum. Vestibular migraine, involving episodic vertigo associated with migraine features, is another frequent cause managed by neurologists.
The neurologist must evaluate the patient to rule out potentially serious, life-threatening causes. Conditions such as brain tumors, infections, or toxicity from medications can present with central nervous system vertigo. By focusing on the brain and its pathways, the neurologist ensures the root cause is identified and addressed. This distinction from inner ear specialists is based on the anatomical location of the disruption causing the balance problem.
Central Versus Peripheral Vertigo
The underlying cause determines whether vertigo is classified as peripheral or central, guiding the choice of specialist. Peripheral vertigo originates in the inner ear’s vestibular labyrinth or the vestibular nerve. This type is far more common, often caused by conditions like Benign Paroxysmal Positional Vertigo (BPPV) or Meniere’s disease. Peripheral episodes are typically intense and sudden, often described as a violent spinning sensation.
Peripheral attacks are usually short-lived, frequently lasting only seconds or minutes, and are often triggered by specific head movements. Associated symptoms are typically auditory, including hearing loss, tinnitus (ringing in the ears), or a feeling of fullness in the affected ear. The involuntary eye movements (nystagmus) that occur with peripheral vertigo are typically unidirectional. They are often reduced or suppressed when the patient focuses their gaze on a fixed object.
Central vertigo arises from dysfunction within the brain, such as the cerebellum or brainstem. This type is generally less intense than peripheral vertigo but tends to be more persistent, sometimes lasting for days or weeks. It may occur suddenly or develop gradually, and is less often triggered by changes in head position. The accompanying symptoms are neurological, often involving double vision (diplopia), slurred speech (dysphonia), difficulty swallowing (dysphagia), or weakness in the limbs.
The nystagmus associated with central vertigo is often multidirectional, meaning the eye movement changes direction with the direction of gaze. Unlike peripheral causes, this nystagmus is usually not suppressed when the patient attempts to fix their gaze. Central vertigo often presents with severe imbalance or difficulty walking (ataxia) that is disproportionate to the subjective feeling of spinning. Recognizing the co-occurrence of these neurological signs is a primary reason a patient is directed toward a neurologist.
How Neurologists Diagnose the Cause of Vertigo
The diagnostic process begins with a detailed patient history, focusing on the character, duration, and triggers of the vertigo episodes and any associated neurological symptoms. The neurologist then performs a comprehensive neurological and physical examination, including assessing gait, coordination, and reflexes. A focused assessment of eye movements is a powerful tool for differentiating central from peripheral causes.
In acute, continuous vertigo, a neurologist may use the HINTS exam (Head Impulse, Nystagmus, and Test of Skew). This three-part bedside examination is highly sensitive for detecting central lesions, such as a stroke, that cause Acute Vestibular Syndrome. The Head Impulse test checks the vestibulo-ocular reflex function. The Nystagmus assessment looks for specific patterns of involuntary eye movement, and the Test of Skew evaluates for vertical ocular misalignment, a strong indicator of a central problem.
If the HINTS exam suggests a central etiology or if the patient presents with other concerning signs, brain imaging is often performed. Magnetic Resonance Imaging (MRI) is the preferred method, as it can detect structural abnormalities like tumors, demyelination plaques characteristic of MS, or signs of a stroke in the brainstem or cerebellum. Early MRI can be less sensitive than the HINTS exam for detecting hyperacute stroke, but it remains the standard for confirming structural causes. Computed Tomography (CT) scans may be used initially in an emergency setting to rule out acute hemorrhage.
Treatment Pathways for Neurological Vertigo
Once a central cause of vertigo is confirmed, the neurologist focuses treatment on the underlying neurological condition. For vertigo caused by an acute stroke, initial management is directed at the cerebrovascular event itself, potentially involving thrombolytic therapy or anticoagulants. Long-term treatment then shifts to stroke recovery and preventing future incidents. Vertigo associated with multiple sclerosis is managed by disease-modifying therapies (DMTs) aimed at reducing disease activity and lesion formation.
In cases of vestibular migraine, treatment follows established protocols for migraine prophylaxis. This typically involves medications such as beta-blockers (e.g., propranolol) or anti-seizure medications (e.g., topiramate). Lifestyle modifications, including avoiding known migraine triggers and dietary changes, are also recommended to reduce the frequency and severity of vertigo attacks.
For all types of neurological vertigo, Vestibular Rehabilitation Therapy (VRT) is a standard part of the long-term treatment plan. VRT is a specialized form of physical therapy designed to retrain the brain to process balance signals more effectively. This therapy helps improve gait stability, balance, and visual function by promoting central compensation for the vestibular deficit. This approach contrasts with physical maneuvers, like the Epley maneuver, used to treat the common peripheral cause of BPPV.