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Vertigo is a perception of movement when none exists that results from a mismatch between the visual, vestibular, and proprioceptive sensory systems. Symptoms of vertigo are classically described by patients as a sensation that “the room is spinning,” but can also include atypical sensations of other types of movement. Vertigo is classified as peripheral or central (Table 144-1). Peripheral vertigo (involving the vestibular apparatus and eighth cranial nerve) usually has a sudden onset with intense symptoms that include nausea, vomiting, intolerance of head movement, and diaphoresis. Central vertigo (involving central structures such as the brainstem or cerebellum) can present either abruptly or gradually, but usually is characterized by less severe symptoms that are not well characterized by patients. Clinicians can work to discriminate between these two types of vertigo during a care encounter in the Emergency Department (ED) while recognizing that some overlap may exist between these two types of vertigo.

Table 144-1

Differentiating Peripheral from Central Causes of Acute Undifferentiated Vertigo


The differential diagnosis for an episode of vertigo (Table 144-2) may be extensive, and providers should evaluate for the presence or absence of some key features during the history and physical examination. Inquire about the speed of symptom onset, severity, duration, temporal pattern, head or neck trauma, chiropractic manipulation, and any associated symptoms such as headache, neck pain, or loss of consciousness. Assess risk factors for stroke such as age, hypertension, cardiovascular disease, and coagulopathy. Physical examination should include eye (e.g., nystagmus), ear, vestibular, and neurological examinations, with particular attention to potential abnormalities of the cranial nerves or cerebellar function. Since focal deficits are not universal in central vertigo, further specialized neurological tests may be of value in some patients. HINTS testing consists of the Head Impulse test (evaluation of the vestibulo-ocular reflex), examination for Nystagmus direction that changes with gaze direction, and Test of Skew (vertical ocular misalignment during the cover-uncover eye test). The presence of one or more findings on the HINTS exam that are consistent with ...

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