There are many causes and classifications of vertigo disorders, so how do you stay active in the midst of the many causes and diagnoses? Medical history, bedside examination, imaging? The first thing to emphasize is medical history, which is always important; in fact, it is the routine bedside examination; and then there is imaging examination, but the most confusing of them all is also the imaging examination. Common imaging examinations include: cervical spine X-ray, TCD, brain CT, brain MRI… I. Cervical spine X-ray, the diagnosis of osteophytes and curvature straightening is commonly reported… Since the proportion of cervical vertigo is already minimal as mentioned in the previous chapter, the diagnosis of such imaging is basically meaningless. In other words, cervical spine X-ray is basically meaningless for the diagnosis of vertigo. Second, TCD examination, common reports show that blood flow is slowed down… The diagnostic and typing criteria of cervical vertigo formulated in the Second National Symposium on Cervical Spondylosis in Qingdao as early as 1993: 1. meeting the diagnostic criteria of cervical spondylosis; 2. having vertigo as the main symptom, accompanied by different degrees of headache, visual symptoms and nerve root signs; 3. having pressure pain at the upper cervical segment and occipital nerve; 4. having abnormal blood flow velocity of vertebrobasilar artery in TCD examination. TCD is mentioned here, and TCD is also very common in the clinic, and the report shows “slowed blood flow”, so the clinician often presumes that the blood flow in the neck is reduced, and further presumes “insufficient blood supply”… In fact, there is a confusion between the concept of “blood flow rate” and “blood flow through the vessel”. This is a matter of physics, so an incorrect basic concept also leads to a false presumption. Slowed flow velocity in the basilar artery detected by TCD is not associated with cervical spondylolisthesis in the vast majority of cases; TCD detects blood flow velocity, not blood flow, and therefore, slowed blood flow does not indicate decreased blood flow. The use of TCD to assist in the diagnosis of “cervical vertigo” is a misunderstanding of TCD. Proper routine TCD is used to diagnose cerebral artery stenosis and to determine collateral opening, i.e., as a type of vascular imaging. C. Head CT, commonly reported as “multiple lacunar infarcts”… Lobar infarcts are common, especially in people over 50 years of age, and are mainly located in the cortex or subcortex… Are cavernous infarcts the cause of vertigo? Back to the basic anatomy lesson, the center of vertigo is in the cerebellum and brainstem, rather, the defect of CT examination is the cerebellum and brainstem, and the structures shown by CT are less clear due to the artifact factor, which is basically not clinically significant for vertigo diagnosis. Therefore, CT examination can be rested in vertigo diagnosis and treatment. MRI of the head is commonly reported as “multiple cavernous infarcts”, but the focus of vertigo diagnosis is on cerebellum and brainstem, and MR imaging is clearer than CT and there are new technologies such as diffusion imaging, which can detect lesions earlier. The question is, when should the test be done? The following situations, need to be noted: 1. Acute first attack of vertigo: simple vertigo with acute onset (seconds) and persistent; acute vertigo + negative head toss test; acute vertigo + headache (especially posterior occipital); acute vertigo + any central signs; acute vertigo + deafness (without typical MD manifestations). 2. Recurrent vertigo episodes: in advanced age, with vascular disease risk factors, without obvious migraine symptoms, when the episodes do not exceed 1 year, and when posterior circulation TIA is not excluded. V. In vertigo diagnosis, cervical spine X-ray, head CT, TCD forget it!