Dizziness, Vertigo, and Imbalance Differential Diagnoses

Updated: Oct 27, 2022
  • Author: Hesham M Samy, MD, PhD; Chief Editor: Robert A Egan, MD  more...
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Diagnostic Considerations

On the basis of the patient’s history and physical findings, the examining physician should be able to formulate a differential diagnosis and determine whether the symptoms are likely to be peripheral or central (see the Table below).

Table. Features Differentiating Peripheral from Central Nystagmus (Open Table in a new window)

System or Reflex

Peripheral Lesions

Central Lesions


Spontaneous nystagmus with eyes closed

Saccades (velocity, accuracy), internuclear ophthalmoplegia, saccadic pursuit, gaze-evoked nystagmus

Vestibulo-ocular reflex (VOR)

Nystagmus without fixation, nystagmus after head shaking, eye-head mismatch, unilateral and bilateral vestibular loss

Hyperactive VOR, failure of fixation suppression (FFS), positional nystagmus, bilateral vestibular loss

Vestibulospinal reflex (VSR)

Cautious gait; normal spontaneous movement; normal, spontaneous, and correct movement

Wide-based gait, minimal spontaneous movement

Differential Diagnoses