Rethinking Vertigo Evaluation in the Emergency Department: Why Diagnosing Benign Paroxysmal Positional Vertigo (BPPV), Not With Early CT or MRI, Most Effectively Reduces Diagnostic Error

In emergency departments, early CT or MRI is frequently used in the evaluation of vertigo, largely driven by concern for posterior circulation stroke. However, early CT is insensitive to posterior fossa ischemia, and early MRI may be falsely negative in the first 24-48 hours. In contrast, benign paroxysmal positional vertigo (BPPV), the most common cause of acute vertigo, remains underdiagnosed despite its characteristic clinical features and effective bedside treatment. This editorial argues that the dominant diagnostic error in vertigo care is not failure to detect rare central causes, but failure to actively identify BPPV. By re-centering vertigo evaluation on careful history-taking, positional testing, and recognition of canal-specific nystagmus patterns, before reflexive imaging, clinicians can reduce diagnostic error and unnecessary testing while maintaining patient safety.