Central Vestibular Disorders and Concussion-Related Dizziness
Central disorders
Central vestibular lesions include stroke, demyelination, tumor, cerebellar degeneration, and migraine. Key exam clues are direction-changing or vertical nystagmus, impaired smooth pursuit, saccadic dysmetria, skew deviation, and normal head impulse in acute severe vertigo. Wallenberg syndrome (lateral medullary infarction) causes vertigo, ipsilateral Horner syndrome, facial numbness, contralateral pain/temperature loss, dysphagia, and ataxia. Cerebellar infarction may present with vertigo and gait instability without limb ataxia.
Vestibular migraine
Vestibular migraine is diagnosed clinically with recurrent vestibular symptoms and migraine features; exam is often normal between attacks. Treatment parallels migraine management.
Concussion-related dizziness
After concussion, dizziness may arise from vestibular, visual, cervical, or autonomic dysfunction. Assessment includes oculomotor testing, VOR, balance, and symptom provocation. Persistent postural-perceptual dizziness (PPPD) is a functional disorder with persistent unsteadiness worsened by upright posture and visual motion, often after a triggering event. It is treated with vestibular rehabilitation, cognitive behavioral therapy, and gradual exposure.
Common traps
Attributing central findings to peripheral disease because vertigo is severe; missing PPPD and over-investigating; failing to screen for mood and sleep issues after concussion.
Worked example
A patient with acute vertigo has normal head impulse, direction-changing nystagmus, and skew deviation. Treat as central until imaging and neurology evaluation exclude stroke.