Which statement best captures a key difference between peripheral and central vertigo on examination?

• A. Peripheral vertigo is always accompanied by vertigo lasting minutes.
• B. Peripheral vertigo often has single-direction nystagmus suppressed by fixation and a positive head impulse test; central vertigo can have gaze-evoked or direction-changing nystagmus and is less likely to be suppressed by fixation.
• C. Central vertigo always presents with hearing loss.
• D. Nystagmus characteristics do not aid differentiation.

Answer: (B)

The crucial distinction on examination is how eye movements and reflexes behave. Peripheral vertigo typically shows a horizontal, unidirectional fast phase that is suppressed when the patient fixes their gaze, and the head impulse test is usually positive (a corrective saccade appears with rapid head turns), indicating a peripheral vestibular deficit. In contrast, central vertigo often features gaze-evoked or direction-changing nystagmus, and the nystagmus is not reliably suppressed by fixation; the head impulse test is often normal because the problem lies in the brain rather than the peripheral vestibular apparatus. Hearing loss is not a reliable differentiator, and duration can vary in both.