Vertigo is the false sensation that either the person or their surroundings are moving or spinning when no actual movement is taking place. It is a common symptom and may be associated with disorders of the inner ear and vestibular system, as well as conditions affecting the central nervous system.

Patients often describe their symptoms in different ways:

• “I feel like the room is spinning.”
• “I am losing my balance.”
• “I feel as if I am on a boat.”
• “I am afraid I might fall.”
• “I feel dizzy when I turn my head.”
• “I feel unsteady when I walk.”
• “I have a feeling of fogginess or heaviness in my head.”

Not all of these sensations represent true vertigo. An accurate description of the symptoms, how they started, their duration, and the factors that trigger them can provide important information for the diagnosis.

Peripheral and Central Vertigo

Depending on the part of the nervous system affected, vertigo may have a peripheral or central cause. Peripheral vertigo is associated with disorders of the vestibular system of the inner ear or the vestibular nerve, which carries information about balance and movement from the inner ear to the brain. Central vertigo is caused by disorders affecting the brain, particularly areas of the brainstem and cerebellum involved in maintaining balance, coordinating movement, and processing vestibular information. Distinguishing between peripheral and central vertigo is particularly important because their causes and treatment can differ significantly.

Symptoms of Vertigo

Vertigo may develop suddenly or gradually and can last from a few seconds to several hours or even days, depending on the underlying cause.

It may be accompanied by:

• nausea or vomiting
• unsteadiness and difficulty walking
• a spinning sensation
• nystagmus, which refers to involuntary eye movements
• tinnitus
• hearing loss
• a sensation of pressure or fullness in the ear
• headache
• sensitivity to head movements

The duration of the episodes and the accompanying symptoms provide important information about the possible cause.

Benign Paroxysmal Positional Vertigo (BPPV)

Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common causes of peripheral vertigo. It occurs when microscopic calcium carbonate crystals, known as otoconia or otoliths, become displaced from their normal location and enter one of the semicircular canals of the inner ear. Certain changes in head position can then cause incorrect movement signals to be sent to the brain.

Vertigo typically occurs when the patient:

• turns over in bed
• lies down or gets out of bed
• suddenly turns the head
• bends down
• looks upward

The episodes are usually intense but brief, often lasting less than one minute. After an episode, a sensation of unsteadiness or “fogginess” may persist for some time.

Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

Benign Paroxysmal Positional Vertigo (BPPV) is diagnosed using specific positional tests, during which the doctor observes whether particular head movements trigger the characteristic vertigo and nystagmus. One of the most commonly used tests is the Dix–Hallpike test. The treatment of Benign Paroxysmal Positional Vertigo (BPPV) does not usually rely primarily on medication. Instead, it is treated with specific canalith repositioning maneuvers, which aim to move the displaced crystals out of the affected semicircular canal. One of the best-known techniques is the Epley maneuver. In many cases, significant improvement can occur after one or a few appropriately performed repositioning maneuvers.

Ménière’s Disease and Vertigo

Ménière’s disease is an inner ear disorder that causes recurrent episodes of vertigo.

It may characteristically be associated with:

• episodes of vertigo
• fluctuating hearing loss
• tinnitus
• a sensation of pressure or fullness in the affected ear

The presence of auditory symptoms together with vertigo is an important finding during the diagnostic evaluation.

Vestibular Neuritis and Labyrinthitis

Vestibular neuritis causes acute dysfunction of the vestibular nerve and typically presents with sudden, severe, and prolonged vertigo, nausea, vomiting, and significant unsteadiness. In typical vestibular neuritis, there is no significant hearing loss. Labyrinthitis, in contrast, involves more extensive dysfunction of the labyrinth and may be accompanied by hearing impairment or tinnitus. Distinguishing between these two conditions is important for appropriate evaluation and management.

Central Vertigo

In some cases, vertigo may be caused by a disorder of the central nervous system.

Possible causes include:

• stroke or transient ischemic attack (TIA)
• vestibular migraine
• multiple sclerosis
• disorders affecting the brainstem
• disorders affecting the cerebellum
• tumors or other structural lesions of the central nervous system

Recognizing a possible central cause is particularly important, as some of these conditions require urgent investigation and treatment.

Vertigo and Stroke

Sudden vertigo can, in some cases, be a manifestation of a stroke, particularly when the posterior circulation of the brain is affected.

Immediate medical assessment is required when sudden vertigo is accompanied by symptoms such as:

• double vision
• difficulty speaking
• difficulty swallowing
• weakness or numbness of the face or limbs
• severe loss of coordination
• new severe difficulty walking or inability to walk
• sudden severe headache
• altered consciousness
• other new neurological symptoms

In these situations, the symptoms should not simply be assumed to represent “inner ear vertigo” without appropriate neurological evaluation.

Diagnosis of Vertigo

The diagnosis of vertigo is initially based on a detailed medical history together with a clinical and neurological examination.

Particular attention is given to:

• how the symptoms started
• the duration of each episode
• the relationship between symptoms and head movements
• the presence of nausea or vomiting
• the presence of tinnitus or hearing loss
• the presence of headache or a history of migraine
• the presence of other neurological symptoms

The examination may include assessment of eye movements and nystagmus, balance, gait, coordination, and cranial nerve function, as well as specific positional tests when BPPV is suspected.

Tests for Vertigo

Not every patient with vertigo requires brain imaging.

Depending on the clinical presentation, investigations may include:

Brain Magnetic Resonance Imaging (MRI): May be used when a central neurological cause is suspected or when the clinical presentation has atypical features.

Brain Computed Tomography (CT): May be used in specific emergency or other clinical situations, depending on the suspected underlying cause.

Hearing Assessment: May be necessary when vertigo is accompanied by hearing loss, tinnitus, or other ear-related symptoms.

Vestibular Testing: In selected cases, specialized tests may be used to assess the function of the vestibular system.

Treatment of Vertigo

The treatment of vertigo depends on the underlying cause and is not the same for every patient.

Management may include:

• canalith repositioning maneuvers for BPPV
• short-term medication for severe nausea and acute vertigo when indicated
• specific treatment of the underlying condition
• vestibular rehabilitation
• balance and gaze-stabilization exercises
• treatment of vestibular migraine when this is the underlying cause
• individualized management of Ménière’s disease
• treatment of vascular or other central neurological causes

Prolonged use of medications that suppress the vestibular system is not appropriate in all cases, as in some conditions it may delay the normal process of vestibular compensation.

Vestibular Rehabilitation

Vestibular rehabilitation is an important part of treatment for patients with persistent dizziness, unsteadiness, or vestibular dysfunction.

It involves individualized exercises that may aim to:

• improve balance
• stabilize vision during head movement
• improve walking
• gradually increase tolerance to movements that trigger symptoms
• reduce the risk of falls

The rehabilitation program is adapted to the underlying cause and the individual needs of each patient.

Neurological Follow-Up for Vertigo

Reassessment is particularly important when vertigo persists, frequently recurs, changes in character, or is accompanied by other neurological symptoms. Correct identification of the cause of vertigo allows the appropriate treatment to be selected and helps avoid unnecessary or prolonged medication use. Early neurological assessment of vertigo, particularly when symptoms are sudden or atypical, is important both for effective treatment and for excluding more serious neurological causes.