Short answer
Peripheral vertigo comes from the inner ear or the balance nerve, as in BPPV, vestibular neuritis or Ménière's disease. Central vertigo comes from the brainstem or cerebellum, for example after a stroke. Peripheral causes are far more common and usually respond well to vestibular therapy. Central causes need prompt medical evaluation, which is why screening for warning signs always comes first.
Answered by Dr. Manan Patel, PT, DPT, TPS, Certified Vestibular Specialist and Therapeutic Pain Specialist. Updated October 18, 2026.
What are the red flags that suggest central vertigo?
Call 911 or go to the emergency department if dizziness comes with any of these:
- Sudden trouble speaking, facial droop, or weakness or numbness on one side
- Double vision or loss of vision
- A sudden, severe or unusual headache
- Being unable to stand or walk without help, even with your eyes open
Sudden hearing loss with vertigo also needs same-day medical care. In the emergency department, a bedside eye movement exam called HINTS, performed by trained clinicians, helps separate stroke from inner ear causes of acute, continuous vertigo1.
How do inner ear and brain-related vertigo behave differently?
Timing and triggers are the most useful clues2. Brief spinning lasting seconds to a minute when you lie down, roll over or look up suggests BPPV. Days of constant vertigo after a cold suggests vestibular neuritis. Repeated attacks lasting hours with ear fullness, ringing and hearing changes suggest Ménière's disease. Central causes more often bring severe imbalance, other neurological symptoms, or eye movements that do not fit any inner ear pattern.
How does a vestibular specialist tell them apart?
At your 60-minute evaluation we watch your eyes under infrared video goggles during positional and head movement tests. Peripheral nystagmus follows predictable patterns, such as the upbeating, torsional nystagmus of posterior canal BPPV3. Patterns that do not fit, for example persistent downbeating nystagmus or abnormal smooth pursuit, saccades or coordination, lead to a same-day referral to your physician or a neurologist instead of treatment.
Where can I get vertigo treatment near Alpharetta, Cumming or Suwanee?
Our Cumming clinic on Peachtree Parkway and our Alpharetta clinic on Ventana Way treat inner ear vertigo with repositioning maneuvers and vestibular rehabilitation, and we coordinate with your physician or neurologist whenever testing points to a central cause. Patients come from Suwanee, Johns Creek, Milton and Roswell, and urgent appointments are available within 48 hours.
Where can I get help in Alpharetta, Cumming and nearby?
Dr. Manan Patel, PT, DPT, TPS and our team of physical therapists see patients from Alpharetta, Johns Creek, Milton, Roswell, Cumming, Suwanee, Sugar Hill, Buford, Duluth and Forsyth County at two North Atlanta clinics. Every visit is 60 minutes, one-on-one, and urgent appointments are available within 48 hours. We are in-network with Traditional Medicare, BCBS / Anthem and Tricare, and offer a $129 rate per visit for self-pay and out-of-network plans. Not sure where to start? Take the free symptom self-check, or visit our Alpharetta clinic or Cumming clinic page.
Cumming clinic
Off GA-400 Exit 13 on Peachtree Parkway
Cumming, GA 30041
Alpharetta clinic
Inside Georgia Brain & Spine Physical Therapy
Alpharetta, GA 30022
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References
- Kattah JC, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009.
- Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurologic Clinics. 2015.
- von Brevern M, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. Journal of Vestibular Research. 2015.
This answer is general education, not a diagnosis or a substitute for an examination. If you have new or worsening symptoms, contact your doctor. Call 911 for sudden severe dizziness with trouble speaking, weakness, numbness, double vision or a severe headache.
