What is true vertigo. How does it differ from other forms of dizziness. What are the main causes of vertigo. What are the typical symptoms of vertigo. How is vertigo diagnosed and treated. What are some effective home remedies for managing vertigo symptoms. When should you see a doctor for vertigo.

What is True Vertigo and How Does it Differ from General Dizziness?

True vertigo refers to a specific type of dizziness characterized by a sensation that either the environment is spinning around you (objective vertigo) or that you yourself are spinning (subjective vertigo). This rotational sensation is key in distinguishing true vertigo from other forms of dizziness. While the term “vertigo” is sometimes used loosely to describe any feeling of dizziness, true vertigo has distinct characteristics:

• Involves a rotational or spinning sensation
• Often originates from issues in the vestibular system
• Can be accompanied by nausea, vomiting, and balance problems
• May be triggered by specific head movements or position changes

Unlike general dizziness, which can include feelings of lightheadedness, unsteadiness, or faintness, true vertigo is a more specific and intense experience. Understanding this distinction is crucial for proper diagnosis and treatment.

Common Causes of Vertigo: From Benign to Serious Conditions

Vertigo can stem from various underlying conditions, ranging from relatively harmless to potentially serious. Some of the most common causes include:

1. Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is the most frequent cause of vertigo, especially in older adults. It occurs when tiny calcium crystals in the inner ear become dislodged and move into the semicircular canals. This leads to brief but intense episodes of vertigo triggered by specific head movements.

2. Meniere’s Disease

This inner ear disorder causes recurring episodes of vertigo along with fluctuating hearing loss, tinnitus (ringing in the ears), and a feeling of fullness in the affected ear. The exact cause is unknown, but it’s believed to be related to fluid buildup in the inner ear.

3. Vestibular Neuritis or Labyrinthitis

These conditions involve inflammation of the inner ear or the vestibular nerve, often due to viral infections. They can cause sudden, severe vertigo that may last for days, accompanied by nausea and balance problems.

4. Acoustic Neuroma

This rare, benign tumor on the vestibular nerve can cause gradual hearing loss, tinnitus, and vertigo as it grows and presses on surrounding structures.

5. Vestibular Migraine

Some people experience vertigo as a symptom of migraine headaches, even without the typical headache pain. This can be challenging to diagnose but is increasingly recognized as a common cause of recurrent vertigo.

6. Stroke or TIA

While less common, vertigo can sometimes be a symptom of a stroke or transient ischemic attack (TIA), particularly if it’s accompanied by other neurological symptoms. This is considered a medical emergency and requires immediate attention.

Recognizing the Symptoms: When Might You Be Experiencing Vertigo?

Identifying vertigo symptoms is crucial for seeking appropriate care. Common signs and symptoms include:

• A sensation of spinning or rotation, either of yourself or your surroundings
• Loss of balance or unsteadiness
• Nausea and vomiting
• Sweating
• Abnormal eye movements (nystagmus)
• Headache
• Ringing in the ears (tinnitus) or hearing loss

The duration and intensity of these symptoms can vary depending on the underlying cause. For instance, BPPV typically causes brief episodes lasting less than a minute, while Meniere’s disease can lead to longer attacks lasting hours.

Diagnostic Approaches: How Do Doctors Identify the Cause of Vertigo?

Diagnosing the specific cause of vertigo often involves a combination of patient history, physical examination, and specialized tests. Here’s an overview of the diagnostic process:

1. Medical History

Your doctor will ask detailed questions about your symptoms, including:

• When the vertigo started
• How long episodes last
• What triggers the symptoms
• Any associated symptoms like hearing loss or tinnitus

2. Physical Examination

This may include:

• Checking blood pressure and heart rate
• Neurological examination to assess balance, coordination, and eye movements
• Ear examination to look for signs of infection or structural abnormalities

3. Specialized Tests

Depending on the suspected cause, your doctor may recommend:

• Dix-Hallpike maneuver to diagnose BPPV
• Electronystagmography (ENG) or videonystagmography (VNG) to evaluate eye movements and vestibular function
• Audiometry to assess hearing
• Imaging studies like MRI or CT scan if a central nervous system cause is suspected

Accurate diagnosis is crucial for determining the most effective treatment approach.

Treatment Options: From Home Remedies to Medical Interventions

The treatment for vertigo depends on its underlying cause. Here are some common approaches:

1. Vestibular Rehabilitation

This form of physical therapy helps train your brain to compensate for inner ear problems. It’s particularly effective for chronic vertigo conditions.

2. Canalith Repositioning Procedures

For BPPV, specific head movements can help relocate the displaced crystals in the inner ear. The Epley maneuver is a common example of this technique.

3. Medications

Various medications can help manage vertigo symptoms:

• Antihistamines like meclizine for motion sickness and vertigo
• Anti-nausea medications
• Diuretics for Meniere’s disease
• Steroids for inflammatory conditions

4. Lifestyle Changes

For some conditions, like Meniere’s disease, dietary changes (such as reducing salt intake) and avoiding triggers can help manage symptoms.

5. Surgery

In rare cases, surgical intervention may be necessary, particularly for conditions like acoustic neuroma or severe, intractable Meniere’s disease.

Living with Vertigo: Coping Strategies and Lifestyle Adjustments

While medical treatments are often necessary, there are several strategies individuals can employ to manage vertigo symptoms and improve quality of life:

1. Environmental Modifications

Making your living space safer can help prevent falls and accidents during vertigo episodes. Consider:

• Removing tripping hazards like loose rugs
• Installing handrails in the bathroom and along staircases
• Using night lights to improve visibility

2. Stress Management

Stress can exacerbate vertigo symptoms in some individuals. Techniques like deep breathing, meditation, or yoga may help reduce stress and potentially lessen the frequency or severity of vertigo attacks.

3. Sleep Hygiene

Maintaining a regular sleep schedule and ensuring adequate rest can help manage vertigo, particularly for those with vestibular migraine or Meniere’s disease.

4. Dietary Considerations

While dietary triggers can vary, some people find relief by:

• Limiting salt intake (especially for Meniere’s disease)
• Reducing caffeine and alcohol consumption
• Staying well-hydrated

5. Exercise and Balance Training

Regular, gentle exercise can improve overall balance and reduce the risk of falls. Activities like tai chi or specific balance exercises prescribed by a physical therapist can be particularly beneficial.

When to Seek Medical Attention: Recognizing Serious Symptoms

While many cases of vertigo are benign and self-limiting, there are situations where immediate medical attention is necessary. It’s important to be aware of red flags that could indicate a more serious underlying condition.

Symptoms Requiring Urgent Care

Seek immediate medical help if vertigo is accompanied by:

• Sudden, severe headache
• Chest pain or irregular heartbeat
• Difficulty speaking or slurred speech
• Weakness or numbness in the face, arm, or leg, especially on one side of the body
• Sudden vision changes or double vision
• Loss of consciousness
• Fever over 101°F (38.3°C)

These symptoms could indicate serious conditions such as stroke, heart problems, or severe infections that require immediate medical intervention.

Persistent or Recurrent Vertigo

While not necessarily an emergency, you should consult a healthcare provider if:

• Vertigo episodes are frequent or severe enough to interfere with daily activities
• Symptoms persist for more than a week
• You experience hearing loss or ringing in the ears along with vertigo
• You have a history of head injury and develop vertigo

Early diagnosis and treatment can often prevent complications and improve outcomes for many vertigo-causing conditions.

Emerging Research and Future Directions in Vertigo Treatment

The field of vertigo research is dynamic, with ongoing studies exploring new understanding and treatment approaches. Some areas of current interest include:

1. Genetic Factors

Researchers are investigating genetic components that may contribute to conditions like Meniere’s disease and vestibular migraine. This could lead to more targeted treatments in the future.

2. Advanced Imaging Techniques

New imaging methods are being developed to better visualize the inner ear and vestibular system, potentially improving diagnosis and treatment planning.

3. Vestibular Implants

Similar to cochlear implants for hearing loss, vestibular implants are being researched to help restore balance function in individuals with severe vestibular disorders.

4. Pharmacological Advancements

New medications targeting specific aspects of vestibular function are in various stages of development and clinical trials.

5. Virtual Reality in Rehabilitation

VR technology is being explored as a tool for vestibular rehabilitation, offering immersive environments for balance training and symptom management.

These advancements hold promise for improving the diagnosis, treatment, and quality of life for individuals suffering from vertigo and related vestibular disorders.

Understanding vertigo, its causes, and treatment options is crucial for anyone experiencing this disorienting condition. While it can be a challenging and sometimes frightening symptom, most cases of vertigo are manageable with proper diagnosis and treatment. By recognizing the signs, seeking appropriate medical care, and implementing coping strategies, individuals with vertigo can often find significant relief and improve their overall quality of life. As research continues to advance our understanding of vestibular disorders, we can look forward to even more effective and targeted treatments in the future.

Overview of vertigo – Summary of relevant conditions

This page compiles our content related to vertigo. For further information on diagnosis and treatment, follow the links below to our full BMJ Best Practice topics on the relevant conditions and symptoms.

Vertigo is the sensation that the environment is spinning around relative to oneself (objective vertigo) or vice versa (subjective vertigo). The term is sometimes used erroneously to mean any form of dizziness. True vertigo is described as a rotary sensation of the patient or surroundings, and is often of vestibular origin. Vertigo may result from diseases of the inner ear or disturbances of the vestibular centers or pathways in the central nervous system (e.g., Meniere disease, arteriosclerosis of cerebral vessels, brain lesion, head injury, motion sickness, or large and rapid variations in barometric pressure).[1]Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82:361-368.
http://www. aafp.org/afp/2010/0815/p361.html

http://www.ncbi.nlm.nih.gov/pubmed/20704166?tool=bestpractice.com
[2]Thompson TL, Amedee R. Vertigo: a review of common peripheral and central vestibular disorders. Ochsner J. 2009 Spring;9(1):20-6.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096243/

http://www.ncbi.nlm.nih.gov/pubmed/21603405?tool=bestpractice.com
Depending on the underlying cause/condition, it may be associated with nausea and vomiting, or accompanied by other symptoms and signs (e.g., headaches and visual symptoms). Most causes of vertigo are peripheral and non-life-threatening. However, those few central causes (vascular and neoplastic) are emergencies that should not be overlooked.

Condition

Description

Evaluation of dizziness

Differentials

go to our full topic on Evaluation of dizziness

Patients may use the term dizziness to describe vertigo, presyncope, disequilibrium and lightheadedness (or nonspecific dizziness). The most common causes of dizziness in primary care settings are benign paroxysmal positional vertigo (vertigo caused by the presence of a canalith in the vestibular apparatus), Meniere disease, and acute vestibular neuritis (vestibular neuronitis).[3]Bösner S, Schwarm S, Grevenrath P, et al. Prevalence, aetiologies and prognosis of the symptom dizziness in primary care – a systematic review. BMC Fam Pract. 2018 Feb 20;19(1):33.
https://www.doi.org/10.1186/s12875-017-0695-0

http://www.ncbi.nlm.nih.gov/pubmed/29458336?tool=bestpractice.com
These all present with vertigo symptoms.

Benign paroxysmal positional vertigo (BPPV)

Signs & symptoms

Investigations

Differentials

Treatment algorithm

go to our full topic on Benign paroxysmal positional vertigo (BPPV)

A peripheral vestibular disorder characterized by sudden-onset, severe attacks of vertigo usually lasting <30 seconds and precipitated by specific head movements (e. g., looking up or bending down, getting up, turning the head, or rolling over to one side in bed).[4]Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003 Sep 30;169(7):681-93.
http://www.cmaj.ca/content/169/7/681.full

http://www.ncbi.nlm.nih.gov/pubmed/14517129?tool=bestpractice.com
Diagnosis is clinical with other key diagnostic factors including episodic vertigo (repeated attacks over days, weeks, or months), absence of associated neurologic or otologic symptoms, normal neurologic exam, and positive Dix-Hallpike maneuver (posterior canal BPPV) or supine lateral head turn (lateral canal BPPV).

Meniere disease

Signs & symptoms

Investigations

Differentials

Treatment algorithm

go to our full topic on Meniere disease

Auditory and vestibular disease characterized by an episodic, sudden onset of vertigo; hearing loss and roaring tinnitus; and a sensation of pressure or discomfort in the affected ear. Vertigo lasts minutes to hours and may be associated with nausea and vomiting. Hearing loss is usually worse during acute attacks, especially in early stages of the disease. As the disease progresses, hearing loss increases in severity and may become constant. Risk factors for Meniere disease include family history, recent viral infection, and autoimmune disorders.

Labyrinthitis

Signs & symptoms

Investigations

Differentials

Treatment algorithm

go to our full topic on Labyrinthitis

An inflammatory condition, which affects the labyrinth in the cochlea and vestibular system of the inner ear. Viral labyrinthitis is typically associated with a preceding upper respiratory tract infection. Other etiologic viral agents include varicella zoster virus, cytomegalovirus, mumps, measles, rubella, and HIV. Bacterial labyrinthitis is associated with acute or chronic otitis media, meningitis, and cholesteatoma. Labyrinthitis may also manifest in certain autoimmune conditions (e. g., Cogan syndrome or Behcet disease).[5]Girasoli L, Cazzador D, Padoan R, et al. Update on vertigo in autoimmune disorders, from diagnosis to treatment. J Immunol Res. 2018 Sep 26;2018:5072582.
https://www.doi.org/10.1155/2018/5072582

http://www.ncbi.nlm.nih.gov/pubmed/30356417?tool=bestpractice.com
Patients typically present with severe room-spinning vertigo and associated nausea and vomiting. They may have unilateral hearing loss and tinnitus. Most acute episodes are short-lived and self-limited.

Vestibular migraine

A common cause of vertigo and the most common cause of spontaneous episodic vertigo.[1]Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82:361-368.
http://www.aafp.org/afp/2010/0815/p361.html

http://www.ncbi.nlm.nih.gov/pubmed/20704166?tool=bestpractice.com
[6]Bisdorff AR. Management of vestibular migraine. Ther Adv Neurol Disord. 2011;4:183-191.
http://journals.sagepub. com/doi/pdf/10.1177/1756285611401647

http://www.ncbi.nlm.nih.gov/pubmed/21694818?tool=bestpractice.com
It affects approximately 10% of patients with migraine.[1]Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82:361-368.
http://www.aafp.org/afp/2010/0815/p361.html

http://www.ncbi.nlm.nih.gov/pubmed/20704166?tool=bestpractice.com
Symptoms include spontaneous and positional vertigo, head motion vertigo/dizziness and ataxia, all of variable duration, ranging from seconds to days, and independent of migraine associated headache.[1]Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82:361-368.
http://www.aafp.org/afp/2010/0815/p361.html

http://www.ncbi.nlm.nih.gov/pubmed/20704166?tool=bestpractice.com
[6]Bisdorff AR. Management of vestibular migraine. Ther Adv Neurol Disord. 2011;4:183-191.
http://journals.sagepub.com/doi/pdf/10.1177/1756285611401647

http://www. ncbi.nlm.nih.gov/pubmed/21694818?tool=bestpractice.com
Photophobia, phonophobia, or aura may be diagnostic symptoms.[1]Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82:361-368.
http://www.aafp.org/afp/2010/0815/p361.html

http://www.ncbi.nlm.nih.gov/pubmed/20704166?tool=bestpractice.com
Management is similar to the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications, and prophylactic therapies (beta blockers, calcium channel blockers, and tricyclic antidepressants).[6]Bisdorff AR. Management of vestibular migraine. Ther Adv Neurol Disord. 2011;4:183-191.
http://journals.sagepub.com/doi/pdf/10.1177/1756285611401647

http://www.ncbi.nlm.nih.gov/pubmed/21694818?tool=bestpractice.com

Vestibular neuritis

Differentials

go to our full topic on Vestibular neuritis

A common cause of unilateral peripheral vestibular loss, vestibular neuritis (vestibular neuronitis) is an acute peripheral vestibulopathy due to reactivation of a viral infection, most commonly herpes simplex virus. It affects the vestibular ganglion, vestibular nerve, labyrinth, or a combination of these sites.[7]Walker MF. Treatment of vestibular neuritis. Curr Treat Options Neurol. 2009;11:41-45.
http://www.ncbi.nlm.nih.gov/pubmed/19094835?tool=bestpractice.com

Cerebrovascular causes

Dizziness is a common presenting feature in cerebrovascular events. Cerebellar stroke (due to infarction or hemorrhage) may present in a similar fashion to peripheral causes of vertigo with sudden intense vertigo, nausea, and vomiting. Nystagmus (bilateral or vertical) may suggest a central cause of the vertigo. Other neurologic signs include limb ataxia and impaired gait. Patients with cerebellar stroke usually cannot stand without support, even with the eyes open, whereas a patient with acute vestibular neuritis or labyrinthitis is usually able to do so. Unlike peripheral causes, the head-impulse test is negative (no saccadic adjustment of the eyes on sudden head twisting).[8]Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg. 1998;119:55-59.
http://www.ncbi.nlm.nih.gov/pubmed/9674515?tool=bestpractice.com
Urgent magnetic resonance imaging should be requested in all patients with acute vertigo who have significant risk factors for a cerebellar stroke, such as hypertension, diabetes mellitus, smoking, and cardiovascular disease, since it is possible that central signs on exam may not present.

Post-traumatic vertigo

Typically, occurs as a result of blunt head trauma such as a fall, an assault, or a motor vehicle accident. Presenting symptoms may be of a traumatic perilymphatic fistula or post-traumatic Meniere disease.[9]Marzo SJ, Leonetti JP, Raffin MJ, et al. Diagnosis and management of post-traumatic vertigo. Laryngoscope. 2004;114:1720-1723.
http://www.ncbi.nlm.nih.gov/pubmed/15454760?tool=bestpractice.com
Patients may complain of vertigo, disequilibrium, tinnitus, pressure, headache, and diplopia. Other causes are postsurgical (middle-ear surgery, cochlear implantation) and diving.[10]Albera R, Canale A, Lacilla M, et al. Delayed vertigo after stapes surgery. Laryngoscope. 2004;114:860-862.
http://www.ncbi.nlm.nih.gov/pubmed/15126744?tool=bestpractice.com
[11]Fina M, Skinner M, Goebel JA, et al. Vestibular dysfunction after cochlear implantation. Otol Neurotol. 2003;24:234-242.
http://www.ncbi.nlm.nih.gov/pubmed/12621338?tool=bestpractice.com
[12]Al Felasi M, Pierre G, Mondain M, et al. Perilymphatic fistula of the round window. Eur Ann Otorhinolaryngol Head Neck Dis. 2011;128:139-141.
http://www.ncbi.nlm.nih.gov/pubmed/21288793?tool=bestpractice.com
Superior semicircular canal dehiscence should be differentiated from post-traumatic vertigo; it is characterized by episodes of vertigo associated with loud sounds and/or altered middle-ear pressure.[13]Banerjee A, Whyte A, Altas MD. Superior canal dehiscence: review of a new condition. Clin Otolaryngol. 2005;30:9-15.
http://www.ncbi.nlm.nih.gov/pubmed/15748182?tool=bestpractice.com

Neoplastic causes

Intracranial tumors and vestibular schwannomas may present with vertigo, as well as other symptoms such as signs of intracranial pressure (e.g., headache, altered mental status, nausea, and/or vomiting) and gait abnormality. Cranial nerve deficits may also manifest.[8]Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg. 1998;119:55-59.
http://www.ncbi.nlm.nih.gov/pubmed/9674515?tool=bestpractice.com
Neuroimaging with computed tomography/magnetic resonance imaging is essential.

Peripheral, Central, BPPV, and More

Written by Paula Ford-Martin

• What Causes Peripheral Vertigo?
• What Other Symptoms May I Have With Peripheral Vertigo?
• How Is Peripheral Vertigo Treated?
• What Causes Central Vertigo?
• What Other Symptoms Could I Have From Central Vertigo?
• How Is Central Vertigo Treated?
• More

If you’ve been on your share of amusement park rides, you probably know what vertigo is like — the feeling that the world is spinning around you. But if you feel dizzy and didn’t just step off a roller coaster, check with your doctor to see if you’ve got one of the two most common forms of vertigo: central and peripheral.

There are drugs and other treatments for both types. Finding out which one you’ve got — and what’s causing it — can help you and your doctor decide how to manage it.

Keep in mind that vertigo is a symptom of a medical condition, not a disease by itself. Your doctor will try to figure out what’s behind it.

If your doctor tells you that you have peripheral vertigo, you’ve got plenty of company. It’s the most common type of vertigo. Most cases are caused by a problem in the inner ear, which controls your balance.

The most common causes of the inner ear trouble that leads to peripheral vertigo are:

• Benign paroxysmal positional vertigo (BPPV)
• Vestibular neuronitis
• Meniere’s disease

BPPV is a condition that causes small crystals to get loose and start to float in the fluid of your inner ear. The movement of the crystals and the fluid leads you to feel dizzy. Sometimes an ear injury can lead to BPPV.

Vestibular neuronitis causes severe dizziness that comes on suddenly and lasts for 2 to 3 weeks. Doctors think an infection with a virus may be the cause.

Meniere’s disease is condition that combines symptoms of dizziness with occasional hearing loss. Doctors aren’t sure what causes it, though stress can be a trigger, along with eating salt or drinking caffeine and alcohol.

There are some other conditions of the inner ear that also lead to peripheral vertigo, including:

• Labyrinthitis
• Perilymph fistula
• Superior semicircular canal dehiscence syndrome (SSCDS)

Labyrinthitis may be caused by a viral infection of your inner ear. Perilymph fistula may be due to a head injury or sudden pressure change, such as from scuba diving. SSCDS may be due to a breakdown of part of a bony part of a canal that carries fluids in your inner ear.

Nausea and vomiting, sweating, and ear problems are all common symptoms that you may have along with vertigo.

If your peripheral vertigo is caused by an inner ear infection or a disease, you may have some pain or a feeling of fullness in your ear.

In labyrinthitis and Meniere’s disease, you may have hearing loss and tinnitus (ringing of the ears) in one or both ears along with the vertigo.

There are some common features of peripheral vertigo that can help your doctor make a diagnosis. Vertigo that starts without warning, and stops just as quickly, is more likely to be peripheral vertigo.

Your eyes may also move without your control. This movement may go away when you try to focus your vision on a fixed point. It also tends to only happen during the first few days of vertigo symptoms and then disappears.

You can treat peripheral vertigo by managing the condition that’s causing it.

BPPV, the most common cause of peripheral vertigo, can be treated with a 15-minute exercise known as the Epley maneuver. This series of movements, done in your doctor’s office, helps return the crystals that control balance to the correct place in your inner ear.

Anti-inflammatory drugs can sometimes help ease symptoms if your peripheral vertigo is caused by vestibular neuronitis, Meniere’s disease, or labyrinthitis. Meniere’s disease can also be controlled by cutting down on salt, caffeine, and alcohol and lowering your stress.

For some conditions, such as perilymph fistula or SSCDS, your doctor may recommend surgery to correct problems in your inner ear.

Some conditions causing peripheral vertigo may be chronic, meaning they are ongoing. In these situations, you’ll need a combination of balance exercises, lifestyle changes, and medication to manage the vertigo. Motion sickness medicine may also help ease nausea. Your doctor may also prescribe medicines that help reduce balance problems.

Central vertigo is caused by a disease or injury to the brain, such as:

• Head injuries
• Illness or infection
• Multiple sclerosis
• Migraines
• Brain tumors
• Strokes
• Transient ischemic attacks (“mini” strokes that last for a short time and don’t cause permanent damage)

While episodes of peripheral vertigo tend to pass quickly, central vertigo often comes without warning and may last for long periods of time. The episodes are generally much more intense than peripheral, and you may be unable to stand or walk without help.

Eye movement that you can’t control happens in both types of vertigo. But in central vertigo this eye movement lasts longer (weeks to months during vertigo episodes) and it does not go away when you’re asked to focus on a fixed point.

The hearing problems that frequently happen in peripheral vertigo or AICA strokeare rare with central vertigo. But other symptoms — like headaches, weakness, or trouble swallowing — are common with central vertigo.

Finding out the root cause of the vertigo and treating it is the only way to manage central vertigo. If migraines are the cause, for instance, medication and reducing your stress may help.

For some ongoing conditions, such as multiple sclerosis stroke, and some tumors, treatment may consist of managing the symptoms. This may include medicines for nausea and drugs that help lessen the sensation of movement.

A stroke in the brain can trigger not only vertigo but dysarthria (slurred speech), ataxia (problems moving), weakness, and numbness/tingling. You should get emergency help right away.

Top Picks

Vestibular vertigo

Dizziness is a feeling of a disturbed orientation of the body in space or an imaginary movement of one’s own body or the environment is one of the most common complaints of patients of any age [1-6]. The probability of occurrence of dizziness and instability during life reaches 20-30% [1-3]. There are vestibular (true) dizziness, feeling of weakness and impending loss of consciousness (pre-fainting), balance and gait disturbance (unstability) and psychogenic dizziness [1, 2, 4].

Vestibular, or true, vertigo is a feeling of imaginary rotation or movement (circling, falling or rocking) of surrounding objects or the patient himself in space; it is often accompanied by nausea, vomiting, imbalance, and nystagmus, and is exacerbated (or appears) with changes in head position and rapid head movement [1–8]. Vestibular vertigo can be central (damage to the vestibular nuclei of the brain stem and their connections with other parts of the brain) or peripheral (damage to the vestibular nerve and labyrinth). Central vertigo is characterized by combined symptoms of damage to the brainstem or cerebellum (disorders of swallowing, voice or sensitivity, diplopia, or other disorders) [1, 2, 8]. Recurrent isolated (without concomitant symptoms) vestibular vertigo is rarely central, it is more often caused by benign paroxysmal positional vertigo (BPPV) or vestibular migraine [1, 2, 8–14].

Despite the emergence of new and accurate instrumental diagnostic methods, a carefully collected anamnesis is still an important part of the examination of a patient with dizziness [1, 2, 8, 12, 15]. In many cases, using a neurological and neurovestibular examination, the most common causes of dizziness, such as BPPV, vestibular neuronitis, Meniere’s disease, vestibular migraine, and cerebrovascular disease, can be detected already at the outpatient stage [1, 2, 12, 15, 16]. Neurovestibular examination and some instrumental methods, such as video oculography, electrocochleography, audiometry, caloric test, etc., help to distinguish between central and peripheral vestibular vertigo [1, 2, 12, 15, 16]. With central vertigo, the methods of X-ray computed tomography and magnetic resonance imaging (MRI) of the brain are of paramount importance in the diagnosis.

In our country, many patients suffering from BPPV, Meniere’s disease or vestibular neuronitis are mistakenly diagnosed with vertebrobasilar insufficiency (VBN) and dyscirculatory encephalopathy (DE) [16—18]. As a result, patients do not receive effective treatment for a long time, many of them develop emotional disorders, which often lead to severe violations of professional, social and household adaptation. Errors in diagnosis are due to insufficient awareness of doctors about the manifestations and diagnosis of the most common causes of peripheral vestibular vertigo [16—21].

Cerebrovascular diseases

Vestibular vertigo can be observed in transient ischemic attack (TIA) or ischemic stroke in the vertebrobasilar system, as well as in cerebellar hemorrhage [16–21]. Vestibular vertigo is less common than other typical stroke manifestations, such as limb paresis, speech and sensory disturbances; out of 993 cases of stroke, vestibular dizziness was observed only in 5% of patients, while limb paresis occurred in 90% of patients, central facial muscle paresis in 58%, sensory disorders in 57%, speech disorders in 37% [18]. In the analysis of symptoms in 280 patients with stroke in the vertebrobasilar system, vestibular vertigo was found in 16% of cases, while it was rarely (less than 1%) isolated [18]. Vestibular vertigo in patients with TIA or ischemic stroke in the vertebrobasilar system, as well as with hemorrhage in the cerebellum, in most cases is combined with other neurological disorders (dysphagia, dysarthria, diplopia, paresis, sensory disorders, trunk ataxia), which distinguishes cerebrovascular accidents from diseases of the labyrinth, manifested by isolated vestibular vertigo [16–18].

A comparatively low (3.2% of cases) probability of stroke or TIA among patients with dizziness hospitalized for emergency reasons was noted in a survey of 1666 patients older than 44 years [ 22 ]. However, there are descriptions of individual cases of recurrent episodes of isolated vestibular vertigo that preceded the development of a stroke and were TIA in the vertebrobasilar system [22, 23]. Therefore, in all cases of vestibular vertigo, in which cerebrovascular accident cannot be ruled out, an MRI of the brain is necessary. In stroke, MRI may show focal lesions of the cerebellum and/or brainstem. Even in the case of negative MRI results, in the presence of a high risk of stroke, dynamic monitoring of a patient suffering from isolated vestibular vertigo is necessary, and repeated MRI of the brain is indicated if dizziness recurs [22, 23].

BPPV

BPPV is the most common form of peripheral vestibular vertigo [1, 2, 9—11, 14]. The disease is associated with the formation of otoliths (calcium carbonate crystals, otolithiasis) in the dome (cupulolithiasis) or channels (canalolithiasis) of the labyrinth and is manifested by bouts of vestibular vertigo that occur when the position of the head changes. An attack of BPPV is characterized by high intensity, accompanied by specific positional nystagmus (horizontal or vertical-torsion), nausea and sometimes vomiting, and lasts no more than 1 minute, but attacks that repeat one after another often give the impression of prolonged dizziness [9-11, 13, 16, 21]. On average, the disease lasts about 2 weeks; approximately ¹ / ₂ cases of BPPV have a recurrent course [9-11 , 13, 16, 21]. The diagnosis of BPPV is based on the anamnesis, the clinical picture of seizures and is confirmed by positional tests. Most often (up to 90% of cases), BPPV of the posterior semicircular canal occurs, the diagnosis of which is confirmed by the Dix-Hallpike test [9-11, 13, 16, 21]. As a rule, an attack of dizziness occurs in the morning when turning from side to side or getting out of bed. Often, an attack of vertigo can cause the head to tilt back in an upright position, which sometimes leads to a fall due to loss of balance. Often an attack of dizziness is accompanied by nausea, less often by vomiting [9-11, 13, 16, 21]. In atypical cases, especially in elderly patients, BPPV may present with only a feeling of unsteadiness without recurring episodes of rotational positional vertigo.

In BPPV, highly effective repositioning maneuvers are performed by trained specialists, as well as Brandt-Daroff vestibular gymnastics performed by the patients themselves [9—11, 13, 16, 21].

Meniere’s disease

Meniere’s disease – the second most common cause of peripheral vestibular vertigo after BPPV – is caused by endolymphatic hydrops (an increase in the volume of endolymph filling the membranous labyrinth of the inner ear), the cause of which is supposed to be a violation of the mechanisms of regulation of the processes of formation and absorption of endolymphatic fluid [4, 8, 16, 20, 21].

The disease is manifested by bouts of vestibular dizziness, progressive sensorineural hearing loss, sensations of noise and fullness in the ear, which can occur in different sequences. Vertigo attacks are presumably caused by a defect in the Reisner membrane of the membranous labyrinth as a result of its stretching and mixing of endo- and perilymph with different electrolyte composition [4, 8, 16, 20, 21]. Hearing loss and tinnitus are explained by the gradual death of spiral ganglion neurons as a result of apoptosis. The disease can occur with a predominance of vestibular or auditory disorders, depending on which there are various variants of the course of Meniere’s disease [4, 8, 16, 20, 21, 24, 25]. The most difficult variant for diagnosis is when at first the disease manifests itself only with bouts of vestibular dizziness, and later (usually within a year) hearing impairments join. This variant of Meniere’s disease is much less common, it is called the vestibular form of Meniere’s disease. Often, dizziness is accompanied by increasing noise and unpleasant sensations of congestion, fullness, or pressure in the ear. Against the background of repeated attacks of rotational dizziness, hearing loss progresses [4, 8, 16, 20, 21]. At first, only one ear is affected, but in the future, in half of the patients, the process also passes to the opposite side.

The diagnosis of Meniere’s disease is based on the clinical manifestations of the disease and typical changes in the audiogram (hearing loss, mainly in the low-frequency region, fluctuation of hearing impairment at the onset of the disease) [4, 8, 16, 20, 21]. The relief of an attack of dizziness in Meniere’s disease is the use of vestibular suppressants and antiemetics. To prevent recurrence of the disease, a salt-restricted diet is recommended; in some cases, acetazolamide and betahistine are prescribed for a long period [4, 8, 16, 20, 21]. When conservative treatment is ineffective and the frequency of vertigo attacks is high, surgical methods of treatment are discussed [4, 8, 16, 20, 21].

Vestibular neuronitis

Vestibular neuronitis is the third most common cause of peripheral vestibular vertigo. It is assumed that the disease occurs as a result of selective damage to the vestibular nerve of viral or infectious-allergic genesis [1–3, 15–17, 20, 21]. In some patients, an attack of severe vestibular vertigo is preceded by a respiratory viral infection, sometimes a few hours or days before the onset of the disease, short-term episodes of dizziness or unsteadiness occur. In the first days of the disease, spontaneous nystagmus can be seen during a clinical neurological examination, but as a result of central compensation, after a few days, when fixing the gaze, nystagmus is no longer detected, but latent spontaneous nystagmus persists for a long time in the absence of gaze fixation. Therefore, videonystagmography is informative, which makes it possible to detect peripheral vestibular nystagmus without fixing the gaze [15–17, 20, 21, 24–27]. After an acute attack, the severity of vertigo decreases significantly within a few days, but there is an imbalance that persists from several weeks to several months, and in the absence of adequate treatment, unsteadiness when turning the head at the same time as walking, walking on uneven surfaces or in low light conditions may persist constantly.

The diagnosis of vestibular neuronitis is based on the typical clinical presentation and confirmed by a positive Halmaga test, vestibular hypo- or areflexia on the caloric test on the side of the lesion. With vestibular neuronitis, hearing is not impaired, there is no noise in the ears and symptoms of brainstem damage, which in most cases makes it possible to exclude Meniere’s disease and ischemic stroke in the vertebrobasilar system [1–3, 15–21, 24–27].

Treatment of vestibular neuronitis at the onset of the disease is symptomatic and aimed at reducing dizziness, nausea and vomiting. The duration of use of vestibular suppressants should not exceed 3 days, since these drugs slow down vestibular compensation [5, 7, 15-18, 20, 21]. In the first 3 days of the disease, the use of methylprednisolone at an initial dose of 100 mg is effective, followed by a dose reduction of 20 mg every 3 days, which leads to a decrease in residual vestibular deficit and accelerated recovery of vestibular function. Of great importance is the early start of vestibular rehabilitation, which includes exercises that stimulate vestibular compensation.

Vestibular migraine

Vestibular migraine (migraine-associated vertigo) occurs in the form of attacks of sudden moderate or severe dizziness. An attack of dizziness lasts from several minutes to several hours, often combined with vomiting, nystagmus, photo- and phonophobia, and headache [11]. Dizziness in vestibular migraine is accompanied by a headache only in some cases, it can be aggravated by changes in the position of the head, acquiring a positional character. A constant combination of an attack of vestibular vertigo with headache is observed only in a small proportion of patients with migraine [2, 11, 16].

The diagnosis of vestibular migraine is based on the typical clinical presentation and the exclusion of other possible causes of vertigo. In the treatment of vestibular migraine, the same principles apply as for the treatment of headache attacks in ordinary migraine [11, 16]. During an attack of dizziness, non-steroidal anti-inflammatory drugs, triptans, dihydroergotamine preparations, and benzodiazepines are used [11, 16]. To prevent frequent attacks of vestibular migraine, beta-blockers, tricyclic antidepressants, acetazolamide, calcium channel blockers, selective serotonin reuptake inhibitors, and antiepileptic drugs are used [7, 11, 16].

Misdiagnosis of vertigo

Unfortunately, at present, many patients suffering from peripheral vestibular vertigo and vestibular migraine have erroneous diagnoses, which reflect the results of our observation of 700 patients (205 men and 495 women) aged 25 to 88 years ( mean age 55±14 years) who applied in 2009—2017. with complaints of dizziness in the clinic of nervous diseases (KNB) of the First Moscow State Medical University. THEM. Sechenov (Sechenov University) [26, 27]. All patients underwent standard somatic, neurological, and neurovestibular examinations, and their emotional status was assessed using the Hospital Anxiety and Depression Scale. Of the instrumental methods of examination, MRI of the brain, videonystagmography, stabilometry, duplex scanning of the main arteries of the head were performed. Some patients underwent tone threshold audiometry, electrocochleography. Patients with suspected psychogenic dizziness are consulted by a psychiatrist. Diagnoses before treatment and after a specialized examination in the KNB are presented in table.

Causes of dizziness identified before and after a specialized examination at the National Security Committee abs.

%

abs.

%

VBN

310

44 9 0003

0

0

DE

255 9Vegetative syndrome 0003

36

14

2 dystonia

74

11

0

0

Dorsopathy of the cervical spine

53

8

0

However, it is not always possible to identify the exact cause immediately and on your own, so you should definitely go to the doctor, preferably a neurologist. It is he who will be able to determine the cause and distinguish true dizziness from another form of the disease. Most often, darkening in the eyes is mistaken for dizziness, if a movement is abruptly performed: turn around or stand up. Doctors call this phenomenon0055 orthostatic collapse (rapid outflow of blood from the head).

Dizziness: how to determine the cause

Unlike true vertigo, in which the vestibular apparatus is affected, in false vertigo, which is described as “it’s getting dark in my eyes”, “I feel bad”, this is usually due to fatigue, decrease in hemoglobin in the blood or blood pressure disorders . Sometimes these are signs of impaired muscle tone or even epilepsy .

Causes of dizziness

Does not apply to dizziness:

• appearance of a veil before the eyes,
• feeling of weakness,
• confusion,
• unsteadiness on legs,
• attacks of nausea,
• feeling of imminent fainting (lightheadedness with severe weakness),
• imbalance with unsteadiness in gait.

Which is not dizziness?

Vertigo is distinguished as a symptom of several pathologies:

• primarily benign vertigo attacks,
• psychogenic vertigo,
• dizziness with migraines,
• Meniere’s disease,
• neuritis of the vestibular nerves,
• brain tumor,
• osteochondrosis in the neck area with circulatory disorders.

The good news is that in the vast majority of cases, dizziness is not a symptom of a serious illness. Such bouts of vertigo spontaneously occur and just as spontaneously pass, they usually occur with sharp turns of the head or body in different directions.

The reason for this phenomenon is a sharp and unusual irritation of the nerves inside the vestibular apparatus by special substances. This usually happens after 50 years. An attack occurs when the head is thrown back, turns in bed, sharp bends. At the same time, it can be nauseating. The attack lasts up to a couple of minutes and passes on its own. The basis of treatment is a set of special exercises that train the vestibular apparatus.

Psychogenic

Such attacks occur in overly emotional and impressionable people with phobias, and in this case there are no true disorders in the vestibular apparatus. At the same time, people describe dizziness as confusion, fog in the head, fear of falling and injury, circling objects and the body.

Usually they occur in stressful situations, indoors, crowded places. At the same time, there are also manifestations of hysteria – a sore or lump in the throat, dull pains in the chest, a feeling of suffocation, bouts of sweating and sleep problems. In this case, the patient should unbutton the shirt collar, if any, offer water and, if possible, take him to fresh air.

Migraine attack

Dizziness: how to determine the cause

Very often dizziness accompanies migraine , aggravating the already unpleasant symptoms.