Central vestibular disorders encompass a broad spectrum of neurological conditions that impair balance and spatial orientation through disruption of central nervous system pathways. Vascular etiologies, particularly posterior circulation strokes involving the anterior inferior and posterior inferior cerebellar arteries, represent common and often emergent causes of central vertigo. Non-vascular contributors include neoplasms such as vestibular schwannoma, demyelinating disorders like multiple sclerosis, vestibular migraine, metabolic insults including Wernicke’s encephalopathy, and drug-induced cerebellar toxicity. Heat stroke and epileptiform activity also represent underrecognized but clinically important sources of vertiginous syndromes. Distinguishing central from peripheral vestibular causes is essential, as delayed recognition of cerebrovascular events carries significant morbidity. Diagnostic tools such as the HINTS (Head-Impulse, Nystagmus, Test-of-Skew) examination and advanced neuroimaging are critical in acute evaluation. Management strategies are directed toward underlying pathology, ranging from acute stroke protocols to tumor resection, disease-modifying therapies, and supportive interventions.