Vertigo: Causes, Symptoms, Treatment and When to Worry

What is vertigo?

Vertigo is a symptom: a false sense of movement, usually rotation, caused by a mismatch between signals from the inner ears, eyes and body. It is different from lightheadedness (feeling faint) or general unsteadiness, although the terms are often mixed. Describing exactly what you feel, how long it lasts and what triggers it helps the doctor find the cause.

The balance organs sit in the inner ear (the semicircular canals and otolith organs); they connect to the brain via the vestibular nerve. Problems anywhere along this pathway can cause vertigo.

BPPV: the most common cause

In benign paroxysmal positional vertigo, calcium carbonate crystals (otoconia) dislodge from one organ and float in a semicircular canal, so head movements send false signals. Typical features include short episodes of intense spinning (seconds to under a minute) triggered by rolling over in bed, looking up, bending down or getting out of bed, often with nausea. It becomes more frequent with age and after head injury, and it does not cause hearing loss.

It is diagnosed with positional tests (such as the Dix–Hallpike manoeuvre) and treated with repositioning manoeuvres (such as the Epley manoeuvre) performed by a doctor or trained physiotherapist, which resolve it in most people after one or a few sessions.

Other causes of vertigo

Vestibular neuritis / labyrinthitis: a viral inflammation of the balance nerve (and the inner ear in labyrinthitis), causing sudden, intense vertigo lasting days, with nausea; labyrinthitis also causes hearing loss.
Ménière’s disease: attacks lasting 20 minutes to 12 hours with ear fullness, tinnitus and fluctuating hearing loss.
Vestibular migraine: recurrent vertigo with migraine features. See vestibular migraine.
Medicines: some antibiotics, diuretics and anticonvulsants can affect the inner ear.
Head injury and whiplash.
Central causes: stroke, multiple sclerosis, tumours (such as vestibular schwannoma), which are less common but serious.
Cervical and anxiety-related dizziness are other possible contributors.

Red flags: vertigo that is an emergency

Sudden onset with double vision, trouble speaking or swallowing, facial droop, weakness or numbness.
Severe sudden headache or neck pain.
Inability to stand or walk without support, even when lying still.
Vertigo after a head injury.
New vertigo with chest pain, palpitations or fainting.
Persistent vertigo with sudden hearing loss in one ear.
Vascular risk factors (high blood pressure, diabetes, atrial fibrillation, smoking, age over 60) increase the importance of ruling out a stroke.

How vertigo is assessed

Your doctor will ask about the type, duration, triggers and associated symptoms, take your blood pressure, and examine your eye movements, balance and hearing. Positional tests diagnose BPPV; a head impulse test, nystagmus and a test of skew (the HINTS exam) can help tell inner ear problems from stroke in acute continuous vertigo. A hearing test, MRI or other tests may be ordered depending on the findings.

Treatment

BPPV: canalith repositioning manoeuvres (Epley or Semont) are highly effective; medicine for BPPV is not recommended by the AAO-HNSF guideline.
Vestibular neuritis: short course of anti-nausea medicines in the first days, then early movement and vestibular rehabilitation; steroids may be considered in the acute phase.
Ménière’s disease: low-salt diet, diuretics, vestibular suppressants during attacks, and other treatments under specialist care.
Vestibular migraine: migraine management, lifestyle and preventive medication.
Vestibular rehabilitation: exercises to retrain balance, helpful in many forms of persistent dizziness.
Medication: vestibular suppressants such as prochlorperazine or antihistamines for a day or two only; prolonged use slows recovery.

What you can do during an episode

Sit or lie down and keep still, focusing on a fixed point.
Avoid sudden movements and do not drive or use machinery.
Stay hydrated and avoid alcohol and caffeine.
Sleep with your head slightly raised if lying flat worsens it.
Get up slowly, sitting on the bed edge first.
Take care to avoid falls: clear paths, use handrails and good lighting.
Do not try the Epley manoeuvre on yourself unless a clinician has shown you which ear is affected and how to do it.

When to see a doctor

Any first episode of vertigo, to establish the cause.
Recurrent episodes or vertigo that interferes with daily life.
Hearing loss, ringing or ear fullness with the dizziness.
Continuous dizziness lasting more than a few days.
Falls or unsteadiness.
Vertigo after starting a new medicine.

Three common situations

Brief spinning when rolling over in bed: typical BPPV; a doctor can confirm and treat with a repositioning manoeuvre.

Severe spinning for days after a cold, with vomiting, without hearing loss: consistent with vestibular neuritis; seek assessment to rule out other causes.

Sudden spinning with slurred speech and a drooping face: call emergency services immediately.

Key points to remember

Vertigo is usually inner ear in origin and often treatable, especially BPPV. Get a proper assessment, recognise emergency signs and avoid long use of dizziness medicines. Vestibular rehabilitation helps many people recover.

This guide is for general information and does not replace an assessment by your own doctor or ENT specialist.

Questions about vertigo

These answers are general information and do not replace an examination or individual medical advice.

What is the most common cause of vertigo?

Benign paroxysmal positional vertigo (BPPV), caused by displaced crystals in the inner ear.

How long does vertigo last?

BPPV episodes last under a minute; vestibular neuritis can last days; Ménière’s attacks last 20 minutes to 12 hours.

Does the Epley manoeuvre work?

Yes, it resolves BPPV in most people, but it should be done after the affected ear has been identified by a clinician.

Can vertigo be caused by anxiety?

Anxiety can cause dizziness and worsen vertigo, but true spinning needs a physical assessment.

When is vertigo an emergency?

When it comes suddenly with double vision, speech difficulty, weakness, numbness, severe headache or inability to walk.

Should I take pills for vertigo?

Vestibular suppressants may be used for a day or two in severe attacks, but they are not appropriate for BPPV and prolong recovery if used for long.

Sources

This guide is for general information and does not replace medical advice. How a problem is diagnosed and treated depends on your examination and medical history. If you think you have an emergency, contact your local emergency services.