In this retrospective clinical study, 20 patients were identified to have atypical positional nystagmus associated with positional vertigo following a thorough history and otoneurologic examination. All patients underwent either computed tomography or magnetic resonance imaging. Eight patients demonstrated radiologic evidence of intracranial pathology; the majority had clinical findings suspicious for central pathology. Of 12 patients with normal intracranial imaging, none had a history or clinical findings suspicious for central pathology. The results of this study suggest that in the absence of clinical findings suspicious for central pathology, atypical positional nystagmus in isolation does not necessarily need to be investigated for central lesions. Clinical review of this patient population, however, is required to determine if there is resolution or evaluation to a recognizable form of inner ear dysfunction.