Which sign is most characteristic of central vertigo compared with peripheral vertigo?

• A. Gaze-evoked nystagmus or direction-changing nystagmus
• B. Purely vertical nystagmus suppressed by fixation
• C. Nystagmus always suppressed by fixation
• D. No nystagmus present

Answer: (D)

Central vertigo most characteristically shows gaze-evoked nystagmus or direction-changing nystagmus. This happens because the brainstem and cerebellar circuits that hold gaze steady are disrupted, so the nystagmus changes its direction depending on where you look. In peripheral vertigo, the nystagmus is typically horizontal or rotary, unidirectional, and is suppressed when the patient fixes their gaze. So the presence of nystagmus that changes with gaze direction is the hallmark pointing toward a central, not peripheral, origin. Nystagmus that is always suppressed by fixation or no nystagmus at all are not as typical for distinguishing central vertigo, since fixation suppression is common in peripheral cases and central signs can include a range of ocular findings, not a complete absence of nystagmus.