Rethinking positional nystagmus: beyond BPPV

Positional nystagmus is a frequently encountered yet often underappreciated clinical sign that provides critical insights into vestibular and central nervous system function. For the general neurologist, recognising and correctly interpreting positional nystagmus can significantly impact diagnostic accuracy and guide appropriate management of common and complex dizziness presentations. The current diagnostic framework for positional nystagmus disproportionately favours BPPV, underestimates central positional nystagmus (CPN), and over-relies on imaging. We argue for a paradigm shift that acknowledges clinical complexity, defines objective diagnostic thresholds, and strengthens neurological training.