Causes
Vertigo can be caused by problems in the inner ear (peripheral vertigo) or in the brain or central nervous system (central vertigo).- Peripheral Vertigo (most common, problems in the inner ear):
- Benign Paroxysmal Positional Vertigo (BPPV): The most common cause, triggered by specific head movements. It occurs when tiny calcium carbonate crystals (otoconia) in the inner ear's utricle become dislodged and move into one of the semicircular canals.
- Ménière's Disease: A disorder of the inner ear that causes episodes of vertigo, ringing in the ears (tinnitus), hearing loss, and a feeling of fullness in the ear.
- Labyrinthitis: Inflammation of the labyrinth (part of the inner ear) usually caused by a viral infection, leading to sudden, severe vertigo, nausea, and sometimes hearing loss.
- Vestibular Neuritis: Inflammation of the vestibular nerve (which sends information about head movement to the brain), typically caused by a viral infection, resulting in sudden, severe vertigo without hearing loss.
- Head injury: Trauma to the head can damage the inner ear or vestibular nerve.
- Certain medications: Some drugs can be ototoxic (damaging to the inner ear) and cause vertigo as a side effect.
- Central Vertigo (problems in the brain or central nervous system):
- Stroke: Can affect parts of the brain involved in balance.
- Migraine: Some types of migraine can cause vertigo, known as vestibular migraine.
- Multiple Sclerosis (MS): A neurological disorder that can affect balance pathways in the brain.
- Brain tumors: Tumors in the cerebellum or brainstem can cause vertigo.
- Transient Ischemic Attack (TIA): A "mini-stroke" that temporarily disrupts blood flow to the brain.
Symptoms
The primary symptom of vertigo is the sensation of spinning or moving. Other symptoms that may accompany vertigo include:- Feeling unbalanced or unsteady
- Nausea and vomiting
- Dizziness
- Lightheadedness
- Abnormal eye movements (nystagmus)
- Headache
- Ringing in the ears (tinnitus)
- Hearing loss
- Sweating
- Double vision or difficulty speaking (more common with central vertigo)
- Weakness in limbs (more common with central vertigo)
Diagnosis
Diagnosing the cause of vertigo involves a thorough medical history, physical examination, and specific tests to assess balance and inner ear function.- Medical history and physical exam: The doctor will ask about your symptoms (when they started, how long they last, what triggers them), any associated symptoms, and your medical history. They will perform a neurological exam and assess your balance and gait.
- Dix-Hallpike maneuver: For suspected BPPV, the doctor moves your head in specific ways to try and trigger vertigo and observe eye movements.
- Vestibular tests:
- Videonystagmography (VNG) or Electronystagmography (ENG): Measure eye movements to assess inner ear and brain function.
- Rotary chair test: Measures eye movements in response to chair rotation.
- Vestibular evoked myogenic potentials (VEMPs): Measure responses from neck muscles to sound, assessing inner ear function.
- Hearing tests (audiometry): To check for hearing loss, especially if Ménière's disease is suspected.
- Blood tests: To rule out other conditions.
- Imaging tests:
- MRI (Magnetic Resonance Imaging) or CT scan: May be ordered to look for problems in the brain (e.g., stroke, tumor, MS) if central vertigo is suspected.
Treatment
Treatment for vertigo depends on the underlying cause.- For BPPV:
- Canalith Repositioning Maneuvers (e.g., Epley maneuver): A series of specific head movements performed by a healthcare professional to move the dislodged crystals back into place in the inner ear.
- For Ménière's Disease:
- Dietary changes: Low-salt diet.
- Medications: Diuretics (to reduce fluid buildup), anti-vertigo medications (e.g., meclizine), anti-nausea medications.
- Injections or surgery: In severe, refractory cases.
- For Labyrinthitis or Vestibular Neuritis:
- Medications: Anti-vertigo medications (e.g., meclizine), anti-nausea medications, corticosteroids (to reduce inflammation), antiviral medications (if viral cause confirmed).
- Vestibular rehabilitation therapy (VRT): Exercises to help the brain adapt to and compensate for inner ear imbalances.
- For Central Vertigo:
- Treatment focuses on addressing the underlying neurological condition (e.g., stroke rehabilitation, migraine management, MS treatment).
- General management:
- Medications: Anti-vertigo drugs (e.g., meclizine, dimenhydrinate) and anti-nausea drugs (e.g., ondansetron) can help manage symptoms temporarily.
- Vestibular rehabilitation therapy (VRT): A specialized form of physical therapy that involves exercises to help the brain learn to compensate for inner ear problems and improve balance.
- Lifestyle adjustments: Avoiding sudden head movements, getting enough sleep, reducing stress, and avoiding triggers like caffeine or alcohol for some individuals.
Sorting Out Vertigo: What Kind, and What to Do
The pattern of an attack, how long it lasts, what sets it off, and what comes with it, sorts most vertigo into a few types before any test is ordered, and decides whether the answer is a five-minute maneuver, rehabilitation, or an emergency room.
Timing tells most of the story
Spinning that lasts seconds and is set off by rolling over or looking up is almost always BPPV. Attacks lasting twenty minutes to hours with ear fullness, ringing, and muffled hearing suggest Meniere's disease. Constant severe vertigo for days, worst at the start and easing slowly, fits vestibular neuritis. Episodes of minutes to hours with a headache, light sensitivity, or a history of migraine point to vestibular migraine, which is treated with migraine prevention rather than ear medication.
BPPV: the maneuver, not the pill
Repositioning maneuvers cure most BPPV in one or two sessions, and our Epley maneuver article shows how it is done. Antihistamine dizziness medicines settle nausea for a day or two but do nothing to move the crystals, and taken longer they slow the brain's own recovery, so they are limited to the first few days. Ondansetron controls vomiting without that cost. BPPV often recurs, and the answer is the same maneuver again.
Rehabilitation after neuritis and Meniere's
After vestibular neuritis, rehabilitation exercises that deliberately provoke mild dizziness retrain the balance system, and starting within the first week or two shortens recovery; bed rest prolongs it. Meniere's is managed with salt restriction, a diuretic, and treatment of each attack, with hearing tracked over time; the tinnitus and hearing loss pages describe what to watch.
When vertigo is a stroke until proven otherwise
New vertigo with double vision, slurred speech, weakness or numbness on one side, a severe new headache, or inability to stand or walk unaided needs emergency care, as does a first attack in anyone with atrial fibrillation or other stroke risk factors. Strokes in the back of the brain can mimic an inner-ear problem, and the eye-movement examination that separates them is done in the emergency department. A TIA that has already passed is investigated just as urgently.
What vertigo is confused with
Lightheadedness on standing is not vertigo and usually reflects orthostatic hypotension, dehydration in the heat, or a blood pressure medication; near-fainting is a circulation problem. Unsteadiness without spinning in older adults is usually a mix of poor vision, neuropathy, and weak legs; our fall prevention guide addresses it. Our ear, nose, and throat team coordinates vestibular testing and rehabilitation. The NIDCD and the American Academy of Otolaryngology publish patient guidance on vertigo and balance disorders.
If spinning attacks keep returning, or you have been taking a dizziness pill for more than a few days without a diagnosis, schedule a visit.