Introduction: Vertigo can be due to a variety of central and peripheral causes. The relative incidence of central causes is underestimated. This may have an important impact of the patients' management and prognosis.

Objective: The objective of this work is to determine the incidence of central vestibular disorders in patients presenting to a vestibular unit in a tertiary referral academic center. It also aims at determining the best strategy to increase the diagnostic yield of the patients' visit.

Methods: This is a prospective observational study on 100 consecutive patients with symptoms suggestive of vestibular dysfunction. All patients completed a structured questionnaire and received bedside and vestibular examination and neuroimaging as required.

Results: There were 69 women and 31 men. Their ages ranged between 28 and 73 (mean 42.48 years). Provisional videonystagmography (VNG) results were: 40% benign paroxysmal positional vertigo (BPPV), 23% suspicious of central causes, 18% undiagnosed, 15% Meniere disease, and 4% vestibular neuronitis. Patients with an unclear diagnosis or central features (41) had magnetic resonance imaging (MRI) and Doppler studies. Combining data from history, VNG, and imaging studies, 23 patients (23%) were diagnosed as having a central vestibular lesion (10 with generalized ischemia/vertebra basilar insufficiency, 4 with multiple sclerosis, 4 with migraine vestibulopathy, 4 with phobic postural vertigo, and 1 with hyperventilation-induced nystagmus).

Conclusions: Combining a careful history with clinical examination, VNG, MRI, and Doppler studies decreases the number of undiagnosed cases and increases the detection of possible central lesions.