Background: Acute vertigo is a frequent cause of dizziness-related Emergency Department (ED) visits and can be diagnostically challenging due to its multifactorial etiology. Differentiating benign peripheral vestibular disorders, such as benign paroxysmal positional vertigo (BPPV) or vestibular neuritis, from central causes like cerebellar or brainstem stroke is of paramount importance to prevent morbidity and mortality. Methods: A prospective, observational study was conducted in a tertiary-care ED over 12 months. Adults with acute vertigo of fewer than 48 hours’ duration were enrolled. Standardized clinical assessment included history, neurological examination, bedside vestibular evaluation (HINTS exam), and neuroimaging when indicated. Management strategies were etiology-directed: repositioning maneuvers or vestibular suppressants for peripheral causes, and urgent neuroimaging plus specialist consultation for suspected central pathology. Results: Among 300 patients, 68% were diagnosed with peripheral vestibular disorders, predominantly BPPV (36%) and vestibular neuritis (22%). Central etiologies accounted for 12% of cases and included ischemic events in the posterior circulation. The HINTS exam demonstrated a sensitivity of 95% and specificity of 90% in differentiating peripheral from central vertigo. Patients with peripheral vertigo benefited significantly from immediate repositioning maneuvers and vestibular suppressants. Those with central causes required urgent neuroimaging and specialist intervention; early diagnosis was associated with improved outcomes. Conclusion: Timely and accurate assessment of acute vertigo in the ED is essential to guide appropriate management and prevent adverse outcomes. Incorporating standardized clinical tools like the HINTS exam and using selective neuroimaging can streamline diagnosis and optimize patient care.