Which feature most strongly suggests a central cause of vertigo in a patient presenting with dizziness and nystagmus?

• A. Vertical nystagmus
• B. Brief duration of dizziness
• C. Improvement with positional changes
• D. Hearing loss with aura

Answer: (A)

Vertical nystagmus points to central involvement of the vestibular pathways. When eye movements show a vertical component, it usually means the brainstem or cerebellar circuits that control gaze and balance are affected, which is a hallmark of a central cause of vertigo. Peripheral vertigo, like that from inner-ear disorders, typically produces horizontal or rotary nystagmus that is unidirectional and often fatigues with repetition.

So, the presence of vertical nystagmus is the strongest clue that the dizziness and nystagmus may arise from a central lesion rather than a peripheral vestibular disorder. The other features mentioned tend to fit peripheral processes: short-lived spells or dizziness and improvement with positional changes are common in BPPV, while hearing loss with aura points toward disorders such as Ménière disease rather than a central cause.