Which statement best describes the differential approach to peripheral, central, and psychogenic vertigo?

• A. The differential approach includes history, HINTS, Dix-Hallpike, MRI as indicated, and evaluation for functional symptoms
• B. Central vertigo presents with abrupt onset spinning vertigo with unidirectional nystagmus
• C. The differential approach excludes MRI in most cases
• D. Psychogenic vertigo shows obvious neurological deficits on exam

Answer: (A)

Understanding vertigo differentiation relies on an integrated assessment that combines history with targeted bedside signs to distinguish peripheral, central, and psychogenic causes. The best approach described here brings together a careful history, the HINTS examination, the Dix-Hallpike maneuver, MRI when indicated, and evaluation for functional symptoms. The history helps sort clues about how the vertigo started, how long it lasts, triggering positions, associated hearing changes, and neurologic features. The HINTS exam—head impulse test, assessment of nystagmus, and the test of skew—is especially informative in acute vestibular syndromes: a normal head impulse test with persistent direction-changing or vertical nystagmus and skew deviation suggests a central problem, while an abnormal head impulse test with a unidirectional horizontal nystagmus points toward a peripheral issue. Dix-Hallpike specifically targets BPPV, a common peripheral cause, by provoking a characteristic positional nystagmus. MRI is used when there is suspicion of a central lesion, such as stroke or mass, and is not always required but should be obtained when red flags or persistent symptoms exist. Lastly, evaluating for functional symptoms helps identify psychogenic vertigo, which may show variability, non-physiological signs, or incongruence with the exam findings, rather than clear objective neurological deficits.

This combination—history, HINTS, Dix-Hallpike, MRI when indicated, and assessment for functional symptoms—best captures a comprehensive, practical method for differentiating peripheral, central, and psychogenic vertigo.