Vertigo is a very complex clinical condition that can be difficult to diagnose, and often patients are prescribed imaging tests to identify or rule out structural lesions. However, the vast majority of conditions that cause vertigo do not in fact show imaging abnormalities, such as vestibular migraine, otoliths, and Meniere’s disease, and the vast majority of vertigo patients have no abnormalities on brain scans. Therefore, clinicians should limit or not require imaging in all patients with vertigo. Not only do imaging tests add to the public and private health care burden, but many of the terms used in the reports are incomprehensible to patients, such as “normal variant,” “unrelated finding,” “benign cyst,” and “age-related degeneration. The terms “normal variant”, “unrelated finding”, “benign cyst”, “age-related degeneration”, etc. can create additional concerns for the patient. Therefore, before prescribing tests to patients with vertigo, it should first be clear which patients need imaging scans and which ones are not necessary. Some patients who have been suffering from the disease for a long time may develop fear, and they are convinced that something is wrong with their brain and ask their doctors to perform imaging tests, which only results in more peace of mind for them. The most important basis for imaging examination is that the patient has signs or symptoms of cranial nerve or neurological lesions, such as vertigo patients combined with more pronounced diplopia, facial tingling, numbness or paralysis of the limbs, unilateral tinnitus or hearing loss, and motor incoordination, weakness or sensory impairment of the limbs. Imaging is required for patients presenting with spontaneous nystagmus, especially vertical or simple torsional nystagmus, whereby patients with central pathology can be identified, but it is not necessary to have some tests for patients with acute peripheral vestibular disease (e.g., vestibular neuritis) or in a recurrent course of a known disease (e.g., vestibular migraine or Meniere’s disease). Patients with otoliths do not need to undergo some tests if it is clear by postural examination that they have otoliths in the middle canal, but in patients with persistent positional vertigo, imaging is necessary for safety reasons in order to exclude central pathologies. Vibrational hallucinations are a common symptom in patients with vertigo, mainly as a subjective illusion that the external scene is moving or shaking. These patients also need a brain scan because most of the causes in these patients are due to central lesions. There are, of course, exceptions, such as patients with motion-induced vibratory hallucinations and bilateral vestibular hypofunction. Determining whether a patient with a gait disorder needs imaging is very difficult. A typical Parkinson’s disease would not require a brain scan, as its scan results are usually normal. A brain scan should be performed when a patient presents with focal signs or symptoms, such as eye movement disorders, cognitive abnormalities and a past history of associated disease (e.g., vascular risk factors, cranial injury, malignancy, autoimmune disease). Patients with signs or symptoms suggestive of spinal cord pathology require immediate MRI, as gait instability caused by spinal cord compression will quickly evolve into permanent paraplegia.